Healthcare Provider Details

I. General information

NPI: 1740451491
Provider Name (Legal Business Name): FARMINGTON EAR, NOSE, AND THROAT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 03/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WEST PINE STREET
FARMINGTON MO
63640
US

IV. Provider business mailing address

501 W PINE ST
FARMINGTON MO
63640
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-8888
  • Fax: 866-291-5617
Mailing address:
  • Phone: 573-756-8888
  • Fax: 866-291-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN W. ROBERTS
Title or Position: OWNER
Credential: D.O.
Phone: 573-756-8888