Provider Demographics
NPI:1477657658
Name:ADVOCATES FOR A HEALTHY COMMUNITY, INC
Entity Type:Organization
Organization Name:ADVOCATES FOR A HEALTHY COMMUNITY, INC
Other - Org Name:JORDAN VALLEY COMMUNITY HEALTH CENTER-PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:417-831-0150
Mailing Address - Street 1:440 E TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1131
Mailing Address - Country:US
Mailing Address - Phone:417-851-1551
Mailing Address - Fax:
Practice Address - Street 1:860 LYNN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-3832
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 3336C0002X
MO20050302203336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOPENDINGMedicaid