Provider Demographics
NPI:1013130483
Name:ST JOHNS CLINIC INC
Entity Type:Organization
Organization Name:ST JOHNS CLINIC INC
Other - Org Name:SJC-LEBANON-OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-829-4264
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:331 HOSPITAL DR
Practice Address - Street 2:SUITE E
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9217
Practice Address - Country:US
Practice Address - Phone:417-533-6540
Practice Address - Fax:417-533-6550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO156FX1800X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO329095806Medicaid
MO329095806Medicaid