Basic Information
| Provider Information | |||||||||
| NPI: | 1013130483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST JOHNS CLINIC INC | ||||||||
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| OtherOrganizationName: | SJC-LEBANON-OPTOMETRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 331 HOSPITAL DR | ||||||||
| Address2: | SUITE E | ||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655369217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175336540 | ||||||||
| FaxNumber: | 4175336550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 09/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178294264 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | MO | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332B00000X | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 329095806 | 05 | MO | MEDICAID |