1295852515 NPI number — CITY OF MINONK OF WOODFORD COUNTY

Table of content: MRS. REBECCA ANN VINCENT LMHC (NPI 1316190218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295852515 NPI number — CITY OF MINONK OF WOODFORD COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF MINONK OF WOODFORD COUNTY
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:
1295852515
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 N CHESTNUT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINONK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61760-1272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-432-2558
Provider Business Mailing Address Fax Number:
309-432-3547

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
636 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINONK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61760-1243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-432-2730
Provider Business Practice Location Address Fax Number:
309-432-3547
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
J
Authorized Official Title or Position:
EMS COORDINATOR
Authorized Official Telephone Number:
309-432-2730

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  22501 , 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)

  • Identifier: 590007853 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0010215109 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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