Basic Information
| Provider Information | |||||||||
| NPI: | 1861547705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTOPHER GREATER AREA RURAL HEALTH PLANNING CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SESSER DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | RCA CLINIC | ||||||||
| City: | CHRISTOPHER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187242401 | ||||||||
| FaxNumber: | 6187242571 | ||||||||
| Practice Location | |||||||||
| Address1: | 6294 STATE HIGHWAY 154 | ||||||||
| Address2: | SESSER DENTAL CLINIC | ||||||||
| City: | SESSER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628842163 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6186256979 | ||||||||
| FaxNumber: | 6186255362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | MITROKA | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 6187242436 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.