Provider Demographics
NPI:1790806842
Name:NORTHWEST HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:NORTHWEST HEALTH SERVICES, INC
Other - Org Name:KING CITY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-232-6818
Mailing Address - Street 1:305 RHODE ISLAND
Mailing Address - Street 2:
Mailing Address - City:KING CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64463
Mailing Address - Country:US
Mailing Address - Phone:660-535-4347
Mailing Address - Fax:660-535-6240
Practice Address - Street 1:305 RHODE ISLAND
Practice Address - Street 2:
Practice Address - City:KING CITY
Practice Address - State:MO
Practice Address - Zip Code:64463
Practice Address - Country:US
Practice Address - Phone:660-535-4347
Practice Address - Fax:660-535-6240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO502111271Medicaid
MOCN7865Medicare ID - Type UnspecifiedRR MEDICARE #
MO502111271Medicaid
261834Medicare ID - Type UnspecifiedFQHC NUMBER KC LOCATION