Healthcare Provider Details

I. General information

NPI: 1033512983
Provider Name (Legal Business Name): ST. LOUIS JC VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CAMP RD
POCAHONTAS AR
72455-9131
US

IV. Provider business mailing address

PO BOX 94462
CLEVELAND OH
44101-4462
US

V. Phone/Fax

Practice location:
  • Phone: 913-578-4409
  • Fax:
Mailing address:
  • Phone: 913-578-4409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579