Provider Demographics
NPI:1871568790
Name:BOTHWELL REGIONAL HEALTH CENTER
Entity type:Organization
Organization Name:BOTHWELL REGIONAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:WIGHTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-8833
Mailing Address - Street 1:3143 WEST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-2116
Mailing Address - Country:US
Mailing Address - Phone:660-826-4909
Mailing Address - Fax:660-826-6960
Practice Address - Street 1:3143 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-2116
Practice Address - Country:US
Practice Address - Phone:660-826-4909
Practice Address - Fax:660-826-6960
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOTHWELL REGIONAL HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-22
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2248282N00000X
332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO27363015OtherBLUE CROSS DME
MO624876504Medicaid
MO22479OtherHEALTHCARE USA MC
MO0395820001Medicare NSC