Provider Demographics
NPI:1023065489
Name:FARMINGTON CLINIC COMPANY LLC
Entity type:Organization
Organization Name:FARMINGTON CLINIC COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-756-4581
Mailing Address - Street 1:PO BOX 9489
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-9489
Mailing Address - Country:US
Mailing Address - Phone:573-756-2123
Mailing Address - Fax:573-756-2761
Practice Address - Street 1:764 WEBER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-3317
Practice Address - Country:US
Practice Address - Phone:573-756-2123
Practice Address - Fax:573-756-2761
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FARMINGTON CLINIC COMPANY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-30
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
MO000014942261Q00000X
MO184-46261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
793806Medicare Oscar/Certification