Provider Demographics
NPI:1104821867
Name:NEVADA MEDICAL CLINIC L.L.C.
Entity type:Organization
Organization Name:NEVADA MEDICAL CLINIC L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-667-6015
Mailing Address - Street 1:900 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3210
Mailing Address - Country:US
Mailing Address - Phone:417-667-6015
Mailing Address - Fax:417-667-4234
Practice Address - Street 1:900 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3210
Practice Address - Country:US
Practice Address - Phone:417-667-6015
Practice Address - Fax:417-667-4234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500921101Medicaid
MO595219007Medicaid
MO263901Medicare Oscar/Certification