Basic Information
| Provider Information | |||||||||
| NPI: | 1154708923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRAIRIE CENTER HEALTH SYSTEMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 718 W KILLARNEY ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618011015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173284500 | ||||||||
| FaxNumber: | 2172391129 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 E VOORHEES ST | ||||||||
| Address2: | |||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618346249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174774500 | ||||||||
| FaxNumber: | 2174436613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | RANEY | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2176933021 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRAIRIE CENTER HEALTH SYSTEMS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | A-0606-0007-A | IL | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 101YA0400X | A06060007A | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 006060007 | 05 | IL | MEDICAID |