Provider Demographics
NPI:1306802632
Name:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Entity type:Organization
Organization Name:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:PO BOX 989
Mailing Address - Street 2:2002 KANELL BOULEVARD
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902-0989
Mailing Address - Country:US
Mailing Address - Phone:573-778-0020
Mailing Address - Fax:573-776-7548
Practice Address - Street 1:2002 KANELL BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4045
Practice Address - Country:US
Practice Address - Phone:573-785-4959
Practice Address - Fax:573-785-6405
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED HEALTH CARE MANAGEMENT SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-25
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO302717707Medicaid
5262580001Medicare PIN
MO302717707Medicaid
MO011013495Medicare PIN