Provider Demographics
NPI:1063493237
Name:OZARKS MEDICAL CENTER
Entity type:Organization
Organization Name:OZARKS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:PINCKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-302-3989
Mailing Address - Street 1:812 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2023
Mailing Address - Country:US
Mailing Address - Phone:417-256-3133
Mailing Address - Fax:417-256-5961
Practice Address - Street 1:812 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2023
Practice Address - Country:US
Practice Address - Phone:417-256-0191
Practice Address - Fax:417-256-5961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO280563206Medicaid
MO294954102Medicaid
MO260563200Medicaid
MO940563208Medicaid