Provider Demographics
NPI:1366770604
Name:CRIDER HEALTH CENTER,INC
Entity type:Organization
Organization Name:CRIDER HEALTH CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE CEO, COO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:HEEBNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-332-8306
Mailing Address - Street 1:1032 CROSSWINDS CT
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-4836
Mailing Address - Country:US
Mailing Address - Phone:636-332-6000
Mailing Address - Fax:363-332-3045
Practice Address - Street 1:1032 CROSSWINDS CT
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-4836
Practice Address - Country:US
Practice Address - Phone:636-332-6000
Practice Address - Fax:363-332-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504605312Medicaid