Provider Demographics
NPI:1457402752
Name:ADVANCED ALTERNATIVE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:ADVANCED ALTERNATIVE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-890-5585
Mailing Address - Street 1:3829 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5376
Mailing Address - Country:US
Mailing Address - Phone:417-890-5585
Mailing Address - Fax:417-877-0970
Practice Address - Street 1:3829 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5376
Practice Address - Country:US
Practice Address - Phone:417-890-5585
Practice Address - Fax:417-877-0970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002013903204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500940903Medicaid
MO500940903Medicaid
000014661Medicare ID - Type Unspecified