# DOCTORS INN CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114117306
- **Authorized official:** DEBBIE A WADE NP (NP)
- **Authorized official phone:** (573) 717-1776

## Contact information

- **Practice address:** 1112 SOUTH BYP STE C, SUITE C, KENNETT, MO 63857-3738
- **Practice address phone:** (573) 717-1776
- **Practice address fax:** (573) 717-1572
- **Mailing address:** 1112 SOUTH BYP, SUITE C, KENNETT, MO 63857-3738
- **Mailing address phone:** (573) 717-1776
- **Mailing address fax:** (573) 717-1572

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 2000148413 | MO | Yes |

## Other

- **Enumeration date:** 07/25/2007
- **Last updated:** 02/26/2010

## 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 |