Provider Demographics
NPI:1316112154
Name:PILOT GROVE RURAL HEALTH CLINIC
Entity type:Organization
Organization Name:PILOT GROVE RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-651-4488
Mailing Address - Street 1:212 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:PILOT GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65276-1005
Mailing Address - Country:US
Mailing Address - Phone:660-834-5100
Mailing Address - Fax:660-834-5101
Practice Address - Street 1:212 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:PILOT GROVE
Practice Address - State:MO
Practice Address - Zip Code:65276-1005
Practice Address - Country:US
Practice Address - Phone:660-834-5100
Practice Address - Fax:660-834-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO507476406Medicaid