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FQHCLA219A FORDLAND CLINIC (Terminated)
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Main Details
Name
FORDLAND CLINIC
Subdivision Name
Tri Lakes Community Health Center
Type
Health Center Program Look-Alike
Site ID
BPS-LAL-011437
340B ID
FQHCLA219A
Grant Number
LALCS00078
Additional Details
Current Program Status
Terminated
Registration Date
7/14/2015
Participating Start Date
10/1/2015
Participating Approval Date
7/29/2015
Last Recertification Date
Termination Date
Termination Reason
4/1/2016
Change of covered entity type
Contacts
Authorizing Official
Fordland
Robert Marsh, Exec. Director
(417) 767-2273 Ext: 2021
Primary Contact
Fordland
Robert Marsh, Exec. Director
(417) 767-2273 Ext: 2021
Addresses
Street Address
11863 State Hwy 13
Kimberling City, MO 65686-0555
Billing Address
Fordland Clinic, Inc
1059 Barton Drive
Fordland, MO 65652-7350
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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