Provider Demographics
NPI:1043891880
Name:FUNCTIONAL REGENERATIVE SERVICES OF ILLINOIS LTD LLC
Entity Type:Organization
Organization Name:FUNCTIONAL REGENERATIVE SERVICES OF ILLINOIS LTD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-FNP-C
Authorized Official - Phone:217-253-2370
Mailing Address - Street 1:902 S COURT STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TUSCOLA
Mailing Address - State:IL
Mailing Address - Zip Code:61953
Mailing Address - Country:US
Mailing Address - Phone:217-253-2370
Mailing Address - Fax:
Practice Address - Street 1:902 S COURT STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953
Practice Address - Country:US
Practice Address - Phone:217-253-2370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-14
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty