Healthcare Provider Details

I. General information

NPI: 1720359243
Provider Name (Legal Business Name): CAPE FAMILY MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2012
Last Update Date: 04/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 N SPRIGG ST
CAPE GIRARDEAU MO
63701-5526
US

IV. Provider business mailing address

24 N SPRIGG ST
CAPE GIRARDEAU MO
63701-5526
US

V. Phone/Fax

Practice location:
  • Phone: 573-332-7992
  • Fax: 573-332-7998
Mailing address:
  • Phone: 573-332-7992
  • Fax: 573-332-7998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: ERIC R GOINES
Title or Position: OWNER
Credential:
Phone: 573-332-7992