Provider Demographics
NPI:1467519058
Name:WESTON FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:WESTON FAMILY CLINIC, LLC
Other - Org Name:WESTON FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHENOWETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-640-2762
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:MO
Mailing Address - Zip Code:64098-0040
Mailing Address - Country:US
Mailing Address - Phone:816-640-2762
Mailing Address - Fax:816-640-5564
Practice Address - Street 1:18215 STATE ROUTE 45 N
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:MO
Practice Address - Zip Code:64098-9101
Practice Address - Country:US
Practice Address - Phone:816-640-2762
Practice Address - Fax:816-640-5564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR1J75207Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE86857Medicare UPIN