Healthcare Provider Details

I. General information

NPI: 1972551943
Provider Name (Legal Business Name): ST CLAIR COUNTY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 ARDUSER DR
OSCEOLA MO
64776-6284
US

IV. Provider business mailing address

530 ARDUSER DR
OSCEOLA MO
64776-6284
US

V. Phone/Fax

Practice location:
  • Phone: 417-646-8332
  • Fax: 417-646-8159
Mailing address:
  • Phone: 417-646-8332
  • Fax: 417-646-8159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR2903
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number96-21
License Number StateMO

VIII. Authorized Official

Name: NANCY MARY STEPHAN
Title or Position: CFO/ADMINISTRATOR
Credential:
Phone: 417-646-8157