Basic Information
| Provider Information | |||||||||
| NPI: | 1669698452 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JCH DIAYSIS CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JERSEY DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 917 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
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| Practice Location | |||||||||
| Address1: | 917 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | HADEN | ||||||||
| AuthorizedOfficialFirstName: | LORRIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENU CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2172238400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BLESSING HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 50353 | 01 | IL | BLUE CROSS | OTHER |