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CHC28965-01 FORDLAND CLINIC (Terminated)
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Main Details
Name
FORDLAND CLINIC
Subdivision Name
Quail Creek Dental
Type
HRSA-Funded Health Center
Site ID
BPS-H80-015503
340B ID
CHC28965-01
Grant Number
H80CS28965
Additional Details
Current Program Status
Terminated
Registration Date
1/5/2016
Participating Start Date
4/1/2016
Participating Approval Date
1/8/2016
Last Recertification Date
2/17/2022
Termination Date
Termination Reason
4/1/2023
Business decision by the Covered Entity
Contacts
Authorizing Official
Fordland Clinic, Inc.
Joan Twiton, Exec. Director
(417) 767-2273 Ext: 2022
Primary Contact
Fordland Clinic, Inc.
Ray Seiberlich, CFO
(417) 767-2273 Ext: 2034
Addresses
Street Address
1440 West Republic Road #144
Springfield, MO 65807-5703
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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