1760508907 NPI number — TAZWOOD MENTAL HEALTH CENTER, INC.

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 1760508907 NPI number — TAZWOOD MENTAL HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TAZWOOD MENTAL HEALTH CENTER, 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:
TMHC EP MH
Provider Other Organization Name Type Code:
5
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:
1760508907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3248 VANDEVER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEKIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61554-6257
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-347-5579
Provider Business Mailing Address Fax Number:
309-347-4264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 W. WASHINGTON STREET
Provider Second Line Business Practice Location Address:
SUITE 230
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-694-6462
Provider Business Practice Location Address Fax Number:
309-694-7812
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MINGUS
Authorized Official First Name:
DAVE
Authorized Official Middle Name:
WALTER
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
309-347-5579

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com