Provider Demographics
NPI:1790970721
Name:CRIDER HEALTH CENTER,INC
Entity Type:Organization
Organization Name:CRIDER HEALTH CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEN VP COO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEEBNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-332-8000
Mailing Address - Street 1:1032 CROSSWINDS CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4836
Mailing Address - Country:US
Mailing Address - Phone:636-332-8000
Mailing Address - Fax:
Practice Address - Street 1:416 MARKET ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2610
Practice Address - Country:US
Practice Address - Phone:636-239-8397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRIDER HEALTH CENTER,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-12
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504605338Medicaid
MO26-1012Medicaid