Provider Demographics
NPI:1427366566
Name:REGIONAL HEALTH CARE CLINIC, INC.
Entity Type:Organization
Organization Name:REGIONAL HEALTH CARE CLINIC, INC.
Other - Org Name:KATY TRAIL - DENTAL - SEDALIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-4774
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2102
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:821 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2102
Practice Address - Country:US
Practice Address - Phone:660-826-4774
Practice Address - Fax:660-826-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509079208Medicaid