1477979078 NPI number — ILLINOIS LIV, LLC

Table of content: (NPI 1477979078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477979078 NPI number — ILLINOIS LIV, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ILLINOIS LIV, LLC
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:
1477979078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51266
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70505-1266
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-233-1307
Provider Business Mailing Address Fax Number:
337-233-5764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7017 JOHN DEERE PKWY STE 2A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOLINE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61265-8037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-623-4022
Provider Business Practice Location Address Fax Number:
309-792-7296
Provider Enumeration Date:
03/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GACHASSIN
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
337-233-1307

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 421436658004 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0974923 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com