Provider Demographics
NPI:1043774342
Name:MONCLAIR ENTERPRISES, INC.
Entity Type:Organization
Organization Name:MONCLAIR ENTERPRISES, INC.
Other - Org Name:MONCLAIR FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:618-281-7010
Mailing Address - Street 1:1000 ELEVEN S STE 2B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-1079
Mailing Address - Country:US
Mailing Address - Phone:618-281-7010
Mailing Address - Fax:618-281-7009
Practice Address - Street 1:1000 ELEVEN S STE 2B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1079
Practice Address - Country:US
Practice Address - Phone:618-281-7010
Practice Address - Fax:949-543-2846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL502787806001Medicaid
1932127891OtherNPI
1962404294OtherNPI