Healthcare Provider Details

I. General information

NPI: 1972554566
Provider Name (Legal Business Name): ST. LOUIS JC VAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 03/18/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 S MOUNT AUBURN RD
CAPE GIRARDEAU MO
63703-9998
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: MS. ERIN POTTER
Title or Position: NPI TEAM MEMBER
Credential:
Phone: 202-382-2579