Basic Information
Provider Information | |||||||||
NPI: | 1306497052 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 577 | ||||||||
Address2: | 109 CALIFORNIA ST | ||||||||
City: | CARTERVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 629180577 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185199200 | ||||||||
FaxNumber: | 6189854635 | ||||||||
Practice Location | |||||||||
Address1: | 1506 SIOUX DR | ||||||||
Address2: |   | ||||||||
City: | MARION | ||||||||
State: | IL | ||||||||
PostalCode: | 629595209 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185199200 | ||||||||
FaxNumber: | 6185199155 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2019 | ||||||||
LastUpdateDate: | 09/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JENSEN | ||||||||
AuthorizedOfficialFirstName: | PATSY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6189569508 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SHAWNEE HEALTH SERVICE AND DEVELOPMENT CORP | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.