Basic Information
| Provider Information | |||||||||
| NPI: | 1669948667 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH IMPROVEMENT CENTER DBA CROSSING HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178774694 | ||||||||
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| Practice Location | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625216252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178774694 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2018 | ||||||||
| LastUpdateDate: | 01/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | WEST | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2178776127 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 300961830001 | 05 | IL | MEDICAID |