# CALVARY MEDICAL CENTER, LLC

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

## Provider details

- **NPI number:** 1528263464
- **Authorized official:** WENDELL A NICKERSON DO (OWNER)
- **Authorized official phone:** (660) 284-4300

## Contact information

- **Practice address:** 450 NEW CREATION ROAD NORTH, NEWARK, MO 63458-9744
- **Practice address phone:** (660) 284-4300
- **Practice address fax:** (660) 284-4339
- **Mailing address:** 450 NEW CREATION ROAD NORTH, NEWARK, MO 63458-9744

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | R9345 | MO | Yes |

## Other

- **Enumeration date:** 06/20/2007
- **Last updated:** 11/09/2010

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 509038808 | — | MO |