Organization
CALVARY MEDICAL CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WENDELL A NICKERSON DO (OWNER)
(660) 284-4300
Entity
Organization
Contact information
Practice address
450 NEW CREATION ROAD NORTH, NEWARK, MO 63458-9744
(660) 284-4300
(660) 284-4339
Mailing address
450 NEW CREATION ROAD NORTH, NEWARK, MO 63458-9744
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
R9345
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
509038808
—
MO
Enumeration date
06/20/2007
Last updated
11/09/2010
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