Provider Demographics
NPI:1639421365
Name:FORDLAND CLINIC, INC.
Entity Type:Organization
Organization Name:FORDLAND CLINIC, INC.
Other - Org Name:TRI-LAKES COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:417-767-2273
Mailing Address - Street 1:1059 BARTON DR
Mailing Address - Street 2:
Mailing Address - City:FORDLAND
Mailing Address - State:MO
Mailing Address - Zip Code:65652-7350
Mailing Address - Country:US
Mailing Address - Phone:417-767-2273
Mailing Address - Fax:
Practice Address - Street 1:11863 STATE HIGHWAY 13
Practice Address - Street 2:
Practice Address - City:KIMBERLING CITY
Practice Address - State:MO
Practice Address - Zip Code:65686
Practice Address - Country:US
Practice Address - Phone:417-739-1995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORDLAND CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-04
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26-1102261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO261102Medicare Oscar/Certification