Basic Information
| Provider Information | |||||||||
| NPI: | 1578598751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENDOTA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MCH DME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 EAST 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155397461 | ||||||||
| FaxNumber: | 8155385516 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 EAST 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | MENDOTA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613429216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155397461 | ||||||||
| FaxNumber: | 8155385516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/03/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KLEIN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8155397461 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | 0001537 | IL | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | 0001537 | IL | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.