Basic Information
| Provider Information | |||||||||
| NPI: | 1679879704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURTON CREEK RURAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 N KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | WEST PLAINS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657752022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172562111 | ||||||||
| FaxNumber: | 4172564858 | ||||||||
| Practice Location | |||||||||
| Address1: | 909 N KENTUCKY AVE | ||||||||
| Address2: | |||||||||
| City: | WEST PLAINS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657752024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172576762 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 01/10/2012 | ||||||||
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| AuthorizedOfficialLastName: | STAUFFER | ||||||||
| AuthorizedOfficialFirstName: | SONJA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4172562111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 2008008964 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 2008008964 | 01 | MO | MO LICENSE | OTHER |