Provider Demographics
NPI:1972812592
Name:DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Entity Type:Organization
Organization Name:DOUGLAS COUNTY PUBLIC HEALTH SERVICES GROUP, INC.
Other - Org Name:MOCH WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINLEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-683-4831
Mailing Address - Street 1:PO BOX 1359
Mailing Address - Street 2:
Mailing Address - City:AVA
Mailing Address - State:MO
Mailing Address - Zip Code:65608-1359
Mailing Address - Country:US
Mailing Address - Phone:417-683-5739
Mailing Address - Fax:417-683-1602
Practice Address - Street 1:603 NW 10TH AVE.
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-683-5739
Practice Address - Fax:417-683-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999135384261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)