Provider Demographics
NPI:1720060304
Name:FC OF MISSOURI INC
Entity Type:Organization
Organization Name:FC OF MISSOURI INC
Other - Org Name:INTREPID USA HEALTHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-445-3750
Mailing Address - Street 1:4055 VALLEY VIEW LN
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5074
Mailing Address - Country:US
Mailing Address - Phone:214-445-3750
Mailing Address - Fax:214-445-3902
Practice Address - Street 1:4305 S. NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2607
Practice Address - Country:US
Practice Address - Phone:417-883-5118
Practice Address - Fax:417-883-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOHHA7502163W00000X, 251E00000X, 376J00000X
MO943539809163W00000X
MO750-7HH251E00000X
MO2635398013747P1801X
MO0002286374U00000X
MO283539807376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO581962909Medicaid
MO283539807Medicaid
MO943539809Medicaid
MO943539809Medicaid