Provider Demographics
NPI:1851373906
Name:HAYTI MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:HAYTI MEDICAL CLINIC, INC
Other - Org Name:EXTENDED HEALTH SYSTEMS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-2930
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-0037
Mailing Address - Country:US
Mailing Address - Phone:573-359-2930
Mailing Address - Fax:573-359-1304
Practice Address - Street 1:1502 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-2571
Practice Address - Country:US
Practice Address - Phone:573-333-4244
Practice Address - Fax:573-333-4551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
263958Medicare ID - Type UnspecifiedRHC PROVIDER NUMBER