Healthcare Provider Details

I. General information

NPI: 1710461942
Provider Name (Legal Business Name): DAVID JOHN EASTHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N MILL ST
FESTUS MO
63028-1816
US

IV. Provider business mailing address

227 MAIN ST
FESTUS MO
63028-1952
US

V. Phone/Fax

Practice location:
  • Phone: 636-931-2700
  • Fax: 636-931-1961
Mailing address:
  • Phone: 636-931-2700
  • Fax: 636-931-5304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023004089
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: