Provider Demographics
NPI:1194019521
Name:PREVENTIVE HEALTHCARE
Entity type:Organization
Organization Name:PREVENTIVE HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:K
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-265-0911
Mailing Address - Street 1:PO BOX 773
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:MO
Mailing Address - Zip Code:65559-0773
Mailing Address - Country:US
Mailing Address - Phone:573-265-0911
Mailing Address - Fax:573-265-0912
Practice Address - Street 1:201 N JEFFERSON ST
Practice Address - Street 2:SUITE D
Practice Address - City:SAINT JAMES
Practice Address - State:MO
Practice Address - Zip Code:65559-1919
Practice Address - Country:US
Practice Address - Phone:573-265-0911
Practice Address - Fax:573-265-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109789261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOB28548Medicare UPIN