Provider Demographics
NPI:1821240896
Name:KNEIBERT CLINIC LLC
Entity Type:Organization
Organization Name:KNEIBERT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:R
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-7175
Mailing Address - Street 1:686 LESTER ST
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-5025
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:
Practice Address - Street 1:686 LESTER ST
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-5025
Practice Address - Country:US
Practice Address - Phone:573-686-2411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR161274722Medicaid