1346546421 NPI number — CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346546421 NPI number — CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL ILLINOIS CENTER FOR TMJ AND FACIAL PAIN, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346546421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
731 SABRINA DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
EAST PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61611-3581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-699-1300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
731 SABRINA DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
EAST PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61611-3581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-699-1300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WALZ
Authorized Official First Name:
JACK
Authorized Official Middle Name:
GLENN
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
309-699-1300

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  019021995 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com