Provider Demographics
NPI:1295778314
Name:HEALTHMONT OF MISSOURI LLC
Entity type:Organization
Organization Name:HEALTHMONT OF MISSOURI LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-642-3376
Mailing Address - Street 1:850 W HOSPITAL DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251
Mailing Address - Country:US
Mailing Address - Phone:573-642-5338
Mailing Address - Fax:573-642-9224
Practice Address - Street 1:850 W HOSPITAL DR
Practice Address - Street 2:SUITE F
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251
Practice Address - Country:US
Practice Address - Phone:573-642-5338
Practice Address - Fax:573-642-9224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014521Medicare PIN
MO268532Medicare ID - Type UnspecifiedRHC PROV NUMBER