Provider Demographics
NPI:1104071455
Name:ANDERSON ISL
Entity type:Organization
Organization Name:ANDERSON ISL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-221-2118
Mailing Address - Street 1:503 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-2405
Mailing Address - Country:US
Mailing Address - Phone:660-221-2118
Mailing Address - Fax:
Practice Address - Street 1:503 E CLARK ST
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-2405
Practice Address - Country:US
Practice Address - Phone:660-221-2118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-27
Last Update Date:2008-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty