Healthcare Provider Details

I. General information

NPI: 1447439633
Provider Name (Legal Business Name): ST JOHNS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 06/30/2008
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: 870-423-4240
  • Fax: 870-423-4241
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberM00127
License Number StateAR

VIII. Authorized Official

Name: DONN E. SORENSEN
Title or Position: SENIOR VICE PRESIDENT/COO
Credential:
Phone: 417-829-4264