Provider Demographics
NPI:1568774503
Name:DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Entity Type:Organization
Organization Name:DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Other - Org Name:MISSOURI OZARKS COMMUNITY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HRO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-683-4831
Mailing Address - Street 1:504 NW 10TH AVE.
Mailing Address - Street 2:PO BOX 1359
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608
Mailing Address - Country:US
Mailing Address - Phone:417-683-4831
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:804 N HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MO
Practice Address - Zip Code:65704-7301
Practice Address - Country:US
Practice Address - Phone:417-924-8809
Practice Address - Fax:417-924-8870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010015973261QD0000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
26-1881OtherMEDICARE PART A
MO505408526Medicaid
MO505408526Medicaid