| Organization Name: | PRIMARY CARE OF BONNE TERRE LLC |
| NPI Number: | 1962883751 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ANDREW J NINICHUCK (OWNER) |
| Mailing Address: | 527 Benham St Bonne Terre |
| State: | MO US |
| Postal Code: | 636281205 |
| Phone Number: | 5733589119 |
| Fax Number: | 5733589489 |
| NPI Enumeration Date: | 06/17/2015 |
| NPI Last Update Date: | 11/23/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |