Basic Information
| Provider Information | |||||||||
| NPI: | 1023083227 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | URBANA SCHOOL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2905 NORTH MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2178773077 | ||||||||
| Practice Location | |||||||||
| Address1: | 1002 SOUTH RACE | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618014449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172394220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | ANDRICKS | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2178776111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.