Provider Demographics
NPI:1639686850
Name:OZARK VALLEY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:OZARK VALLEY MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ASHTON
Authorized Official - Last Name:DERGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-317-5330
Mailing Address - Street 1:5571 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-7488
Mailing Address - Country:US
Mailing Address - Phone:417-317-5330
Mailing Address - Fax:417-763-3370
Practice Address - Street 1:5571 N 21ST ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:MO
Practice Address - Zip Code:65721-7488
Practice Address - Country:US
Practice Address - Phone:417-317-5330
Practice Address - Fax:417-763-3370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFT UP SOMEONE TODAY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-01-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017017409207Q00000X
MO2017024744207Q00000X
MO2017032792208VP0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty