Provider Demographics
NPI:1891341665
Name:GREAT MINES HEALTH CENTER
Entity Type:Organization
Organization Name:GREAT MINES HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEBACK
Authorized Official - Suffix:
Authorized Official - Credentials:MA,NCC,LPC,PHR,SHRMC
Authorized Official - Phone:573-438-9355
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-0761
Mailing Address - Country:US
Mailing Address - Phone:573-438-9355
Mailing Address - Fax:573-438-7892
Practice Address - Street 1:512 STATE ST RM 101
Practice Address - Street 2:
Practice Address - City:MINERAL POINT
Practice Address - State:MO
Practice Address - Zip Code:63660-8208
Practice Address - Country:US
Practice Address - Phone:573-438-9355
Practice Address - Fax:573-438-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
H80CS06870-13-02OtherHRSA