Provider Demographics
NPI:1295058287
Name:SALT RIVER COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:SALT RIVER COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HYNEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-4422
Mailing Address - Street 1:3145 N HIGHWAY 61
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-6588
Mailing Address - Country:US
Mailing Address - Phone:573-221-4422
Mailing Address - Fax:537-221-4403
Practice Address - Street 1:248 N MORGAN ST
Practice Address - Street 2:
Practice Address - City:KAHOKA
Practice Address - State:MO
Practice Address - Zip Code:63445-1433
Practice Address - Country:US
Practice Address - Phone:660-727-1500
Practice Address - Fax:660-727-1502
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALT RIVER COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-05
Last Update Date:2011-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19782870261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1750422457OtherNPI (PARENT ORGANIZATION)
MO833215221OtherMEDICARE-PTAN