Provider Demographics
NPI:1720012677
Name:BENTON CO. PUBLIC HEALTH
Entity Type:Organization
Organization Name:BENTON CO. PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CTIII
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:KEYTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-438-2876
Mailing Address - Street 1:PO BOX 935
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:MO
Mailing Address - Zip Code:65355-0935
Mailing Address - Country:US
Mailing Address - Phone:660-438-2876
Mailing Address - Fax:660-438-5746
Practice Address - Street 1:1238 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-3157
Practice Address - Country:US
Practice Address - Phone:660-438-2876
Practice Address - Fax:660-438-5746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO512062100Medicaid
MO512062100Medicaid