Provider Demographics
NPI:1053533539
Name:REGIONAL HEALTH CARE CLINIC INC
Entity type:Organization
Organization Name:REGIONAL HEALTH CARE CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-438-2717
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:
Practice Address - Street 1:17571 N DAM ACCESS RD
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:MO
Practice Address - Zip Code:65355-6396
Practice Address - Country:US
Practice Address - Phone:660-438-2717
Practice Address - Fax:660-438-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO509079216Medicaid
32293018OtherBCBS
MO509079216Medicaid
MON060000Medicare PIN