Basic Information
| Provider Information | |||||||||
| NPI: | 1194794917 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CROSSING HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2173308770 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2173308770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDRICKS | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2178779117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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) |
ID Information
| ID | Type | State | Issuer | Description | 300961830001 | 05 | IL | MEDICAID |