Provider Demographics
NPI:1477909372
Name:PROFESSIONAL CLINICS, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICS, LLC
Other - Org Name:CONVENIENT HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-335-4715
Mailing Address - Street 1:624 OLD SAINT MARYS RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-1837
Mailing Address - Country:US
Mailing Address - Phone:573-547-3232
Mailing Address - Fax:573-547-3231
Practice Address - Street 1:624 OLD SAINT MARYS RD
Practice Address - Street 2:SUITE A
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-1837
Practice Address - Country:US
Practice Address - Phone:573-547-3232
Practice Address - Fax:573-547-3231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1758OtherMEDICARE PART B
MA1758OtherMEDICARE PART B