Basic Information
| Provider Information | |||||||||
| NPI: | 1780707406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST JOHNS CLINIC INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SJC-MOUNTAIN GROVE | ||||||||
| 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: | 120 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN GROVE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657111039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4179266111 | ||||||||
| FaxNumber: | 4179266115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 06/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | SORENSEN | ||||||||
| AuthorizedOfficialFirstName: | DONN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178294264 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.