Provider Demographics
NPI:1750563722
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:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:573-438-8321
Mailing Address - Street 1:530 N MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1570
Mailing Address - Country:US
Mailing Address - Phone:573-756-8660
Mailing Address - Fax:573-756-5414
Practice Address - Street 1:530 N MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1570
Practice Address - Country:US
Practice Address - Phone:573-756-8660
Practice Address - Fax:573-756-5414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty