Provider Demographics
NPI:1417924606
Name:PETTIS COUNTY HEALTH CENTER
Entity Type:Organization
Organization Name:PETTIS COUNTY HEALTH CENTER
Other - Org Name:PETTIS COUNTY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:F
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, CPNP, MSN RN
Authorized Official - Phone:660-827-1130
Mailing Address - Street 1:911 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-7733
Mailing Address - Country:US
Mailing Address - Phone:660-827-1130
Mailing Address - Fax:660-827-1141
Practice Address - Street 1:911 E 16TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-7733
Practice Address - Country:US
Practice Address - Phone:660-827-1130
Practice Address - Fax:660-827-1141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MON/A251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO512095704Medicaid
MO512095704Medicaid
MO9004118Medicare ID - Type UnspecifiedCMS MEDICARE