Provider Demographics
NPI:1841398773
Name:FARMINGTON CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:FARMINGTON CLINIC COMPANY LLC
Other - Org Name:BONNE TERRE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:SLIPKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-764-3000
Mailing Address - Street 1:TWO CORPORATE CENTRE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-2662
Mailing Address - Country:US
Mailing Address - Phone:615-764-3000
Mailing Address - Fax:615-764-3030
Practice Address - Street 1:55 NESBIT DR
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1353
Practice Address - Country:US
Practice Address - Phone:573-358-1480
Practice Address - Fax:573-358-1489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FARMINGTON CLINIC COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO15054OtherMEDICARE GROUP NUMBER
MO504907908Medicaid
MO504907908Medicaid