1861648958 NPI number — SUPERIOR HEALTH CARE CONCEPTS INC

Table of content: (NPI 1861648958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861648958 NPI number — SUPERIOR HEALTH CARE CONCEPTS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR HEALTH CARE CONCEPTS INC
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:
1861648958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2906 W CLARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMPAIGN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61822-2809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-355-2680
Provider Business Mailing Address Fax Number:
217-355-5538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2906 W CLARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61822-2809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-355-2680
Provider Business Practice Location Address Fax Number:
217-355-5538
Provider Enumeration Date:
08/08/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
217-355-2680

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  203.000084 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X , with the licence number: 203.000084 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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