1225338155 NPI number — SGOH ACQUISITION, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225338155 NPI number — SGOH ACQUISITION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SGOH ACQUISITION, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OCH WELLPOINTE FAMILY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225338155
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2828 N NATIONAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65803-4306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-837-4000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 W HUBBLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARSHFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65706-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-859-4878
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
417-837-4090

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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