Facts
- Status
- A
- Credential
- D.O.
- Type
- Individual
- Enumeration date
- 2006-10-03
- Last updated
- 2024-03-18
Licenses
- License MO
- MO2001026670
- License MO
- 2001026670
- License MO
- MO2001026670
Location
- Practice location
- 1059 BARTON DR
- City
- FORDLAND MO
- Postal code
- 656527350
- Phone
- 417-767-2273
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.