Provider Demographics
NPI:1851428593
Name:CLARK COUNTY NURSING SERVICE & HOME HEALTH AGENCY
Entity Type:Organization
Organization Name:CLARK COUNTY NURSING SERVICE & HOME HEALTH AGENCY
Other - Org Name:CLARK COUNTY HEALTH DEPARTMENT HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:M
Authorized Official - Middle Name:EVELENA
Authorized Official - Last Name:SUTTERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:660-727-2356
Mailing Address - Street 1:670 N JOHNSON ST
Mailing Address - Street 2:P O BOX 12
Mailing Address - City:KAHOKA
Mailing Address - State:MO
Mailing Address - Zip Code:63445-1430
Mailing Address - Country:US
Mailing Address - Phone:660-727-2356
Mailing Address - Fax:
Practice Address - Street 1:670 N JOHNSON ST
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445-1430
Practice Address - Country:US
Practice Address - Phone:660-727-2356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO260562707Medicaid