Provider Demographics
NPI:1750480885
Name:FARMINGTON CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:FARMINGTON CLINIC COMPANY LLC
Other - Org Name:MINERAL AREA PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:PO BOX 504354
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:573-756-5701
Mailing Address - Fax:573-756-7107
Practice Address - Street 1:1101 WEBER RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3326
Practice Address - Country:US
Practice Address - Phone:573-756-5701
Practice Address - Fax:573-756-7107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FARMINGTON CLINIC COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO15057OtherMEDICARE GROUP NUMBER
MO=========OtherTAX ID