Basic Information
| Provider Information | |||||||||
| NPI: | 1831635770 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSING HEALTHCARE ON WATER ST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178779117 | ||||||||
| FaxNumber: | 2173308770 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 N WATER ST | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625231022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173305676 | ||||||||
| FaxNumber: | 2173305992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2017 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANDRICKS | ||||||||
| AuthorizedOfficialFirstName: | TANYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2178779117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH IMPROVEMENT CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.