# BONNE TERRE HEALTH CLINIC LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1104071935
- **Authorized official:** MR. ANDREW JOHN NINICHUCK M.D. (MEMBER)
- **Authorized official phone:** (573) 358-3343

## Contact information

- **Practice address:** 55 NESBIT DR, BONNE TERRE, MO 63628-1353
- **Practice address phone:** (573) 358-3343
- **Practice address fax:** (573) 358-5458
- **Mailing address:** 55 NESBIT DR, BONNE TERRE, MO 63628-1353
- **Mailing address phone:** (573) 358-3343
- **Mailing address fax:** (573) 358-5458

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 102387 | MO | — |
| 261QR1300X | Rural Health Clinic/Center | 102387 | MO | Yes |

## Other

- **Enumeration date:** 11/20/2008
- **Last updated:** 09/24/2009