Provider Demographics
NPI:1972551943
Name:ST CLAIR COUNTY HEALTH CENTER
Entity type:Organization
Organization Name:ST CLAIR COUNTY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:STEPHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-646-8157
Mailing Address - Street 1:530 ARDUSER DR
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:MO
Mailing Address - Zip Code:64776-6284
Mailing Address - Country:US
Mailing Address - Phone:417-646-8332
Mailing Address - Fax:417-646-8159
Practice Address - Street 1:530 ARDUSER DR
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:MO
Practice Address - Zip Code:64776-6284
Practice Address - Country:US
Practice Address - Phone:417-646-8332
Practice Address - Fax:417-646-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2903207Q00000X
MO96-21261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD597951300Medicaid
MD597951300Medicaid