Provider Demographics
NPI:1477728244
Name:DALE FAMILY MEDICINE
Entity Type:Organization
Organization Name:DALE FAMILY MEDICINE
Other - Org Name:EMINENCE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-4488
Mailing Address - Street 1:HWY 106 WEST
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:MO
Mailing Address - Zip Code:65466
Mailing Address - Country:US
Mailing Address - Phone:573-226-5216
Mailing Address - Fax:
Practice Address - Street 1:106 HIGHWAY WEST
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:MO
Practice Address - Zip Code:65466
Practice Address - Country:US
Practice Address - Phone:573-226-5216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO598235703Medicaid
MO598235703Medicaid