Provider Demographics
NPI:1801051347
Name:BRUCE A. MEGENHARDT
Entity type:Organization
Organization Name:BRUCE A. MEGENHARDT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MEGENHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-751-1080
Mailing Address - Street 1:3251 BAGNELL DAM BLVD
Mailing Address - Street 2:STE 123
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-9745
Mailing Address - Country:US
Mailing Address - Phone:636-751-1080
Mailing Address - Fax:
Practice Address - Street 1:3251 BAGNELL DAM BLVD
Practice Address - Street 2:STE 123
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9745
Practice Address - Country:US
Practice Address - Phone:636-751-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health