Provider Demographics
NPI:1588858997
Name:SOUTHWEST MO FOOT CLINICS
Entity Type:Organization
Organization Name:SOUTHWEST MO FOOT CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:B
Authorized Official - Last Name:RICHINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-782-7500
Mailing Address - Street 1:PO BOX 3592
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3592
Mailing Address - Country:US
Mailing Address - Phone:417-782-7500
Mailing Address - Fax:417-782-7524
Practice Address - Street 1:2024 S MAIDEN LN STE 201
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-0319
Practice Address - Country:US
Practice Address - Phone:417-782-7500
Practice Address - Fax:417-782-7524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006009605332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626280200Medicaid
MOP00408461OtherRAILROAD MEDICARE PROVIDE
MODG0016OtherRAILROAD MEDICARE GROUP
MO212522OtherBCBS MO
MO000015173OtherMEDICARE GROUP MO
KS114142OtherKANSAS MEDICARE PROVIDER
KS114206OtherKANSAS MEDICARE GROUP
MO301595708Medicaid
KS20422090BMedicaid
MO504920901Medicaid
MO5775120001Medicare NSC
MO626280200Medicaid
MO301595708Medicaid