Facts
- Status
- A
- Credential
- RDH
- Type
- Individual
- Enumeration date
- 2023-04-26
- Last updated
- 2023-04-26
Specialties
Licenses
- License MO
- 2023014634
Location
- Practice location
- 2209 OAK RIDGE DR
- City
- NEOSHO MO
- Postal code
- 648509092
- Phone
- 417-451-0977
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.