Provider Demographics
NPI:1710320643
Name:A PATTERN HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:A PATTERN HEALTH CLINIC, INC
Other - Org Name:A PATTERN HEALTH CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNEX
Authorized Official - Middle Name:
Authorized Official - Last Name:LUBERISSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-886-9852
Mailing Address - Street 1:1674 SOUTH ODELL AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340
Mailing Address - Country:US
Mailing Address - Phone:660-886-9852
Mailing Address - Fax:816-787-1368
Practice Address - Street 1:1674 S ODELL AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3365
Practice Address - Country:US
Practice Address - Phone:660-886-9852
Practice Address - Fax:816-787-1368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01272547261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center