Basic Information
| Provider Information | |||||||||
| NPI: | 1154626448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPARTA COMMUNITY HOSPITAL DBA QUALITY HEALTHCARE CLINICS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SPECIALTY CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 818 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622861820 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 818 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184432177 | ||||||||
| FaxNumber: | 6184431358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2011 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYES | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6184432177 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.