Provider Demographics
NPI:1932521648
Name:ESSENTIAL FAMILY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:ESSENTIAL FAMILY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN, APN, MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, APN
Authorized Official - Phone:573-714-6337
Mailing Address - Street 1:1369 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3313
Mailing Address - Country:US
Mailing Address - Phone:573-714-6337
Mailing Address - Fax:
Practice Address - Street 1:1369 NORTH WESTWOOD BLVD.
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-714-6337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126637261QP2300X
MOR9B65261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG20849Medicare UPIN
MOS30880Medicare UPIN