Healthcare Provider Details

I. General information

NPI: 1750563722
Provider Name (Legal Business Name): GREAT MINES HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MIDDLE ST
FARMINGTON MO
63640-1570
US

IV. Provider business mailing address

530 N MIDDLE ST
FARMINGTON MO
63640-1570
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-8660
  • Fax: 573-756-5414
Mailing address:
  • Phone: 573-756-8660
  • Fax: 573-756-5414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL L. JOHNSON
Title or Position: CEO
Credential: MBA
Phone: 573-438-8321