Provider Demographics
NPI:1669654638
Name:GREAT MINES HEALTH CENTER
Entity Type:Organization
Organization Name:GREAT MINES HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-438-9355
Mailing Address - Street 1:123 W PRATT ST
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:MO
Mailing Address - Zip Code:63020-2107
Mailing Address - Country:US
Mailing Address - Phone:636-586-2522
Mailing Address - Fax:636-586-2546
Practice Address - Street 1:123 W PRATT ST
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:MO
Practice Address - Zip Code:63020-2107
Practice Address - Country:US
Practice Address - Phone:636-586-2522
Practice Address - Fax:636-586-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty