Provider Demographics
NPI:1508310293
Name:SUCCESS HEALTH SYSTEM, LLC
Entity Type:Organization
Organization Name:SUCCESS HEALTH SYSTEM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:MOSES
Authorized Official - Middle Name:TABE
Authorized Official - Last Name:AMBILICHU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-974-0109
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-0716
Mailing Address - Country:US
Mailing Address - Phone:972-974-0109
Mailing Address - Fax:573-271-5108
Practice Address - Street 1:607 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3723
Practice Address - Country:US
Practice Address - Phone:972-974-0109
Practice Address - Fax:573-271-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011019835101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty