Provider Demographics
NPI:1730359340
Name:KIRKSVILLE ALLERGY AND ASTHMA, LLC
Entity type:Organization
Organization Name:KIRKSVILLE ALLERGY AND ASTHMA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:TALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-627-2553
Mailing Address - Street 1:610 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2477
Mailing Address - Country:US
Mailing Address - Phone:660-627-2553
Mailing Address - Fax:660-665-0448
Practice Address - Street 1:610 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-2477
Practice Address - Country:US
Practice Address - Phone:660-627-2553
Practice Address - Fax:660-665-0448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO19139861207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500382205Medicaid
MO500382205Medicaid