Provider Demographics
NPI:1982057501
Name:MIDWEST HEALTH GROUP CONVENIENT CARE, LLC
Entity type:Organization
Organization Name:MIDWEST HEALTH GROUP CONVENIENT CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:573-358-1700
Mailing Address - Street 1:55 NESBIT DR
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1353
Mailing Address - Country:US
Mailing Address - Phone:573-358-1700
Mailing Address - Fax:573-358-1702
Practice Address - Street 1:550 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1981
Practice Address - Country:US
Practice Address - Phone:573-454-2466
Practice Address - Fax:573-454-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site