Basic Information
| Provider Information | |||||||||
| NPI: | 1295194009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN IL REGIONAL WELLNESS CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1736 KINGSHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622042135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184827922 | ||||||||
| FaxNumber: | 6182154048 | ||||||||
| Practice Location | |||||||||
| Address1: | 1736 KINGSHIGHWAY | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622042135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184827922 | ||||||||
| FaxNumber: | 6182154048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| AuthorizedOfficialLastName: | FREELAND | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6184827922 | ||||||||
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| 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 | 1336258540 | 01 | IL | NPI | OTHER |