Provider Demographics
NPI:1972704815
Name:SHARE
Entity Type:Organization
Organization Name:SHARE
Other - Org Name:DANCING HORIZON FAMILY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:HHP CHT PSYD
Authorized Official - Phone:417-429-2180
Mailing Address - Street 1:514 N WEST BYPASS
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802
Mailing Address - Country:US
Mailing Address - Phone:417-429-2180
Mailing Address - Fax:417-832-9799
Practice Address - Street 1:514 N WEST BYPASS
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802
Practice Address - Country:US
Practice Address - Phone:417-429-2180
Practice Address - Fax:417-832-9799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X, 175F00000X, 251V00000X
MORIF83207Q00000X
MOR1200208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251V00000XAgenciesVoluntary or Charitable
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO501465009Medicaid
MO501465009Medicaid