MEDICARE: ST. LOUIS JC VAMC

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	261QV0200X	VA Clinic/Center

General Provider Information

NPI Number	:	1639113798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LOUIS JC VAMC

Provider Business Mailing Address
First Line	:	PO BOX 94462
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44101-4462
Country	:	US
Telephone Number	:	913-578-4409
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E STATE ROUTE K
Second Line	:
City	:	WEST PLAINS
State	:	MO
Zip	:	65775-9998
Country	:	US
Telephone Number	:	913-578-4409
Fax Number	:

Authorized Official
Title or Position	:	NPI TEAM MEMBER
Name	:	ERIN POTTER
Credential	:
Telephone Number	:	202-382-2579

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	01/17/2018

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