Provider Demographics
NPI:1053694422
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:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-378-2351
Mailing Address - Street 1:821 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2102
Mailing Address - Country:US
Mailing Address - Phone:660-826-4774
Mailing Address - Fax:660-826-1300
Practice Address - Street 1:1109 CLAY RD.
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084
Practice Address - Country:US
Practice Address - Phone:573-378-2351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-22
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
MO1053694422Medicaid
MA3685OtherMEDICARE PART B
261053Medicare Oscar/Certification