Basic Information
| Provider Information | |||||||||
| NPI: | 1003187402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. JOHN'S CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
| FaxNumber: | 4178294316 | ||||||||
| Practice Location | |||||||||
| Address1: | 940 W MOUNT VERNON ST | ||||||||
| Address2: | |||||||||
| City: | NIXA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657149609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4177245437 | ||||||||
| FaxNumber: | 4177245433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2012 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AMBULATORY CARE | ||||||||
| AuthorizedOfficialTelephone: | 4178206556 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | MO | RURAL HEALTH MEDICARE | OTHER |