Provider Demographics
NPI:1780053470
Name:HAWKINS COMPASSIONATE CARE CLINIC LLC
Entity type:Organization
Organization Name:HAWKINS COMPASSIONATE CARE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:RN/FNP-C
Authorized Official - Phone:636-775-2479
Mailing Address - Street 1:107B N LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MO
Mailing Address - Zip Code:63379-1315
Mailing Address - Country:US
Mailing Address - Phone:636-775-2479
Mailing Address - Fax:636-775-2480
Practice Address - Street 1:107B N LINCOLN DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-1315
Practice Address - Country:US
Practice Address - Phone:636-775-2479
Practice Address - Fax:636-775-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOF1007042305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service