Provider Demographics
NPI:1972925444
Name:CROSS TRAILS MEDICAL CENTER
Entity Type:Organization
Organization Name:CROSS TRAILS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-339-1196
Mailing Address - Street 1:1314 BRENDA AVE
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-2624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1314 BRENDA AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-2624
Practice Address - Country:US
Practice Address - Phone:573-332-0808
Practice Address - Fax:573-339-7945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-17
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty