Provider Demographics
NPI:1811036791
Name:MANSFIELD CLINIC, INC.
Entity Type:Organization
Organization Name:MANSFIELD CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-924-3066
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-0108
Mailing Address - Country:US
Mailing Address - Phone:417-924-3066
Mailing Address - Fax:417-924-3925
Practice Address - Street 1:304 WEST COMMERCIAL STREET
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MO
Practice Address - Zip Code:65704
Practice Address - Country:US
Practice Address - Phone:417-924-3066
Practice Address - Fax:417-924-3925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263940OtherRIVERBEND GBA
MO596020602Medicaid
MO000013886Medicare ID - Type Unspecified