Provider Demographics
NPI:1518212331
Name:OZARKS MEDICAL CENTER DBA RIVERWAYS SUPPORT SERVICES
Entity Type:Organization
Organization Name:OZARKS MEDICAL CENTER DBA RIVERWAYS SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-256-0191
Mailing Address - Street 1:114 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775
Mailing Address - Country:US
Mailing Address - Phone:417-256-0191
Mailing Address - Fax:417-256-5961
Practice Address - Street 1:114 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-3556
Practice Address - Country:US
Practice Address - Phone:417-256-0191
Practice Address - Fax:417-256-5961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO940563208251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063493237Medicaid
MOM280563206Medicaid
MO1639338759Medicaid
MO1710146832Medicaid