Provider Demographics
NPI:1285896993
Name:MONTGOMERY COUNTY COMMUNITY CLINIC, INC
Entity type:Organization
Organization Name:MONTGOMERY COUNTY COMMUNITY CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:VM
Authorized Official - Last Name:KLEINBECK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, PHD
Authorized Official - Phone:620-331-8190
Mailing Address - Street 1:PO BOX 612
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:KS
Mailing Address - Zip Code:67301-0612
Mailing Address - Country:US
Mailing Address - Phone:620-331-8190
Mailing Address - Fax:620-652-4143
Practice Address - Street 1:900 W MYRTLE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:INDEPENDENCE
Practice Address - State:KS
Practice Address - Zip Code:67301-3242
Practice Address - Country:US
Practice Address - Phone:620-331-8190
Practice Address - Fax:620-652-4143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSNONE REQUIRED261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care