Healthcare Provider Details

I. General information

NPI: 1063517613
Provider Name (Legal Business Name): FARMINGTON CLINIC COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 GARRETT ST
FREDERICKTOWN MO
63645-1084
US

IV. Provider business mailing address

PO BOX 504354
SAINT LOUIS MO
63150-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-4683
  • Fax: 573-783-4684
Mailing address:
  • Phone: 573-783-4683
  • Fax: 573-783-4684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateMO

VIII. Authorized Official

Name: MICHAEL PORTACCI
Title or Position: PRESIDENT
Credential:
Phone: 615-465-7029