Provider Demographics
NPI:1477893907
Name:MISSOURI STATE UNIVERSITY
Entity Type:Organization
Organization Name:MISSOURI STATE UNIVERSITY
Other - Org Name:THE KITCHEN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN, MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-837-1500
Mailing Address - Street 1:MISSOURI STATE DEPARTMENT OF NURSING
Mailing Address - Street 2:901 S. NATIONAL AVENUE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65897-0001
Mailing Address - Country:US
Mailing Address - Phone:417-836-5310
Mailing Address - Fax:417-836-5484
Practice Address - Street 1:1630 N JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-2819
Practice Address - Country:US
Practice Address - Phone:417-837-1504
Practice Address - Fax:417-837-1545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013003462261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health