Healthcare Provider Details

I. General information

NPI: 1013130483
Provider Name (Legal Business Name): ST JOHNS CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 HOSPITAL DR SUITE E
LEBANON MO
65536-9217
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-533-6540
  • Fax: 417-533-6550
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMO

VIII. Authorized Official

Name: DONN E. SORENSEN
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 417-829-4264