Basic Information
| Provider Information | |||||||||
| NPI: | 1811587579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIE CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 W UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173668107 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 W WASHINGTON ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618561713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177623352 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2021 | ||||||||
| LastUpdateDate: | 01/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | PIERCE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2173668107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 01/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.