Healthcare Provider Details

I. General information

NPI: 1003187402
Provider Name (Legal Business Name): ST. JOHN'S CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2012
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 W MOUNT VERNON ST
NIXA MO
65714-9609
US

IV. Provider business mailing address

PO BOX 2580
SPRINGFIELD MO
65801-2580
US

V. Phone/Fax

Practice location:
  • Phone: 417-724-5437
  • Fax: 417-724-5433
Mailing address:
  • Phone: 417-829-4620
  • Fax: 417-829-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: DONN E. SORENSEN
Title or Position: VICE PRESIDENT AMBULATORY CARE
Credential:
Phone: 417-820-6556