MEDICARE: FARMINGTON CLINIC COMPANY LLC

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	207Q00000X	Family Medicine Physician		MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15057	OTHER	MO	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1750480885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FARMINGTON CLINIC COMPANY LLC

Provider Business Mailing Address
First Line	:	PO BOX 504354
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63150-0001
Country	:	US
Telephone Number	:	573-756-5701
Fax Number	:	573-756-7107

Provider Business Practice Location Address
First Line	:	1101 WEBER RD
Second Line	:	SUITE 101
City	:	FARMINGTON
State	:	MO
Zip	:	63640-3326
Country	:	US
Telephone Number	:	573-756-5701
Fax Number	:	573-756-7107

Authorized Official
Title or Position	:	DIRECTOR OF PROVIDER ENROLLMENT
Name	:	DEBBIE E BREWER
Credential	:	MBA
Telephone Number	:	877-892-9813

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/21/2022

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Directions to “FARMINGTON CLINIC COMPANY LLC ” Practice Location

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