Provider Demographics
NPI:1497012652
Name:ST. LOUIS JC VAMC
Entity Type:Organization
Organization Name:ST. LOUIS JC VAMC
Other - Org Name:HARRISBURG VA CBOC
Other - Org Type:Other Name
Authorized Official - Title/Position:NPI TEAM MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-382-2579
Mailing Address - Street 1:PO BOX 94462
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4462
Mailing Address - Country:US
Mailing Address - Phone:913-578-4409
Mailing Address - Fax:913-578-4536
Practice Address - Street 1:608 ROLLIE MOORE DRIVE
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-9998
Practice Address - Country:US
Practice Address - Phone:913-578-4409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-12
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA