Healthcare Provider Details

I. General information

NPI: 1477909372
Provider Name (Legal Business Name): PROFESSIONAL CLINICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 OLD SAINT MARYS RD SUITE A
PERRYVILLE MO
63775-1837
US

IV. Provider business mailing address

624 OLD SAINT MARYS RD SUITE A
PERRYVILLE MO
63775-1837
US

V. Phone/Fax

Practice location:
  • Phone: 573-547-3232
  • Fax: 573-547-3231
Mailing address:
  • Phone: 573-547-3232
  • Fax: 573-547-3231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. AMELIA D LEDBETTER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 573-335-4715