Basic Information
| Provider Information | |||||||||
| NPI: | 1316031958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAMC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4309 SW HICKORY LANE | ||||||||
| Address2: | |||||||||
| City: | BS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64015 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | VAMC | ||||||||
| Address2: | |||||||||
| City: | 4801 LINWOOD BLVD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168614700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | WILMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ARNP | ||||||||
| AuthorizedOfficialTelephone: | 8168614700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 281P00000X | 063151 | MO | Y | Hospitals | Chronic Disease Hospital |
No ID Information.