Healthcare Provider Details

I. General information

NPI: 1447323399
Provider Name (Legal Business Name): ST JOHNS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 ORCHARD DR
BERRYVILLE AR
72616-5013
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 870-423-7171
  • Fax: 870-423-1032
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC4889
License Number StateAR

VIII. Authorized Official

Name: VICKIE JENKINS
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 417-829-4264