Provider Demographics
NPI:1962459768
Name:OUR LADY QUEEN OF PEACE CENTER, INC.
Entity Type:Organization
Organization Name:OUR LADY QUEEN OF PEACE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:573-893-6279
Mailing Address - Street 1:909 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-2945
Mailing Address - Country:US
Mailing Address - Phone:573-893-6279
Mailing Address - Fax:573-893-7248
Practice Address - Street 1:909 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-2945
Practice Address - Country:US
Practice Address - Phone:573-893-6279
Practice Address - Fax:573-893-7248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
I15679Medicare UPIN
PENDINGMedicare ID - Type Unspecified