MEDICARE: ST JOHNS CLINIC INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies		MO

General Provider Information

NPI Number	:	1548467012
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST JOHNS CLINIC INC

Provider Business Mailing Address
First Line	:	PO BOX 2580
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65801-2580
Country	:	US
Telephone Number	:	417-829-4620
Fax Number	:	417-829-4316

Provider Business Practice Location Address
First Line	:	107 W ELDON ST
Second Line	:
City	:	SAINT JAMES
State	:	MO
Zip	:	65559-1903
Country	:	US
Telephone Number	:	573-265-1818
Fax Number	:	573-265-1810

Authorized Official
Title or Position	:	SENIOR VICE PRESIDENT
Name	:	DONN E. SORENSEN
Credential	:
Telephone Number	:	417-829-4264

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	06/30/2008

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