Provider Demographics
NPI:1750697322
Name:CARTER P FENTON SR CLINICS INC
Entity type:Organization
Organization Name:CARTER P FENTON SR CLINICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:P
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-887-3688
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:CHAFFEE
Mailing Address - State:MO
Mailing Address - Zip Code:63740-0098
Mailing Address - Country:US
Mailing Address - Phone:573-887-3688
Mailing Address - Fax:573-887-9022
Practice Address - Street 1:206 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHAFFEE
Practice Address - State:MO
Practice Address - Zip Code:63740-1002
Practice Address - Country:US
Practice Address - Phone:573-887-3688
Practice Address - Fax:573-887-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-20
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO31606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240965905Medicaid
MO240965905Medicaid