Provider Demographics
NPI:1568502631
Name:SGOH ACQUISITION INC
Entity Type:Organization
Organization Name:SGOH ACQUISITION INC
Other - Org Name:OCH LAWRENCE COUNTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-837-4000
Mailing Address - Street 1:108 S HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1407
Mailing Address - Country:US
Mailing Address - Phone:417-466-4110
Mailing Address - Fax:417-466-4255
Practice Address - Street 1:108 S HICKORY ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1407
Practice Address - Country:US
Practice Address - Phone:417-466-4110
Practice Address - Fax:417-466-4255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SGOH ACQUISITION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-07
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO591234208Medicaid
MO591234208Medicaid