Provider Demographics
NPI:1538181409
Name:DANCING HORIZON HEALTH FOUNDATION, INC.
Entity type:Organization
Organization Name:DANCING HORIZON HEALTH FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LOUDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:HHP CHT PSYD
Authorized Official - Phone:417-429-2180
Mailing Address - Street 1:PO BOX 5111
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802
Mailing Address - Country:US
Mailing Address - Phone:417-429-2180
Mailing Address - Fax:417-832-9799
Practice Address - Street 1:2400 BOONSLICK DRIVE
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233
Practice Address - Country:US
Practice Address - Phone:660-882-9840
Practice Address - Fax:660-882-3504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORIF83207Q00000X
MO261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202805958Medicaid
MO501465009Medicaid
MO501465009Medicaid
MO202805958Medicaid
MO000015362Medicare PIN