1174932586 NPI number — PROMISE HEALTHCARE AT THE COMMUNITY RESOURCE CENTER

Table of content: (NPI 1174932586)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174932586 NPI number — PROMISE HEALTHCARE AT THE COMMUNITY RESOURCE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMISE HEALTHCARE AT THE COMMUNITY RESOURCE CENTER
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:
6
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:
1174932586
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
819 BLOOMINGTON 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:
61820-2101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-356-1558
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 W PARK ST
Provider Second Line Business Practice Location Address:
BUILDING 3
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-356-1558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
217-403-5401

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; 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