Basic Information
| Provider Information | |||||||||
| NPI: | 1235455130 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COLES COUNTY COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2905 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2178773077 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 BROADWAY AVENUE EAST | ||||||||
| Address2: | SUITE 39 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172343091 | ||||||||
| FaxNumber: | 2172343094 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2010 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2178776111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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.