Provider Demographics
NPI:1033565882
Name:CLARK-LINDSEY VILLAGE INC.
Entity Type:Organization
Organization Name:CLARK-LINDSEY VILLAGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:REARDANZ
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:217-344-2144
Mailing Address - Street 1:101 W WINDSOR RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-6663
Mailing Address - Country:US
Mailing Address - Phone:217-344-2144
Mailing Address - Fax:217-344-9147
Practice Address - Street 1:101 W WINDSOR RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-6663
Practice Address - Country:US
Practice Address - Phone:217-344-2144
Practice Address - Fax:217-344-9147
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLARK-LINDSEY VILLAGE INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-11
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL145381Medicare UPIN