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Organization
DOCTORS INN CLINIC LLC
Active
Organization
DOCTORS INN CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBBIE A WADE NP (NP)
(573) 717-1776
Entity
Organization
Contact information
Practice address
1112 SOUTH BYP STE C, SUITE C, KENNETT, MO 63857-3738
(573) 717-1776
(573) 717-1572
Mailing address
1112 SOUTH BYP, SUITE C, KENNETT, MO 63857-3738
(573) 717-1776
(573) 717-1572
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
2000148413
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
109494A-001
BLUE CROSS MISSOURI
MO
01
—
150606001
ARKANSAS MEDICAID
MO
05
—
595409004
—
MO
01
—
SM707
BLUE CROSS ARKANSAS
MO
Enumeration date
07/25/2007
Last updated
02/26/2010
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