1427244482 NPI number — FARMINGTON CLINIC COMPANY LLC

Table of content: (NPI 1427244482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427244482 NPI number — FARMINGTON CLINIC COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARMINGTON CLINIC COMPANY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427244482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 WEBER ROAD, SUITE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63640-3325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-756-2600
Provider Business Mailing Address Fax Number:
573-756-2615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
POST OFFICE BOX 504354
Provider Second Line Business Practice Location Address:
ST. LOUIS
Provider Business Practice Location Address City Name:
ST. LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63150-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-756-2600
Provider Business Practice Location Address Fax Number:
573-756-2615
Provider Enumeration Date:
09/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CALLAHAN
Authorized Official First Name:
JEAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PROVIDER ENROLLMENT
Authorized Official Telephone Number:
573-701-7346

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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