Provider Demographics
NPI:1922280189
Name:PLUNKETT FAMILY CARE CENTER LLC
Entity Type:Organization
Organization Name:PLUNKETT FAMILY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-686-5564
Mailing Address - Street 1:2480 THREE RIVERS BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2318
Mailing Address - Country:US
Mailing Address - Phone:573-686-5564
Mailing Address - Fax:573-686-2838
Practice Address - Street 1:2480 THREE RIVERS BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2318
Practice Address - Country:US
Practice Address - Phone:573-686-5564
Practice Address - Fax:573-686-2838
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLUNKETT FAMILY CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3284207Q00000X, 261QP2300X
MO143295363LF0000X
MO089729363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA1473OtherRAILROAD MEDICARE