Provider Demographics
NPI:1962134114
Name:CIRCLE MAKER LLC
Entity type:Organization
Organization Name:CIRCLE MAKER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-461-3009
Mailing Address - Street 1:320 W MOUNT VERNON BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1940
Mailing Address - Country:US
Mailing Address - Phone:417-461-0056
Mailing Address - Fax:
Practice Address - Street 1:320 W MOUNT VERNON BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1940
Practice Address - Country:US
Practice Address - Phone:417-461-0056
Practice Address - Fax:833-707-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-27
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205890106Medicaid