Provider Demographics
NPI:1497273106
Name:ITS A WONDERFUL LIFE LLC
Entity Type:Organization
Organization Name:ITS A WONDERFUL LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-239-0125
Mailing Address - Street 1:110 BUSINESS PARK DR STE C
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7449
Mailing Address - Country:US
Mailing Address - Phone:417-239-0125
Mailing Address - Fax:417-239-0127
Practice Address - Street 1:110 BUSINESS PARK DR STE C
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7449
Practice Address - Country:US
Practice Address - Phone:417-239-0125
Practice Address - Fax:417-239-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005019384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO206293805Medicaid