Facts
- Status
- A
- Credential
- HIS
- Type
- Individual
- Enumeration date
- 2023-08-30
- Last updated
- 2023-08-30
Specialties
Licenses
- License MO
- 2023035504
Location
- Practice location
- 102 PROGRESS PKWY
- City
- SULLIVAN MO
- Postal code
- 630802359
- Phone
- 573-878-1177
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
The OIG NPI list is not in this build yet. Confirm on OIG's search.
Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.