Provider Demographics
NPI:1063654937
Name:LEWIS MEMORIAL CHRISTIAN VILLAGE
Entity Type:Organization
Organization Name:LEWIS MEMORIAL CHRISTIAN VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGHEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-587-7903
Mailing Address - Street 1:3400 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7917
Mailing Address - Country:US
Mailing Address - Phone:217-793-4062
Mailing Address - Fax:217-787-9601
Practice Address - Street 1:3400 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-7917
Practice Address - Country:US
Practice Address - Phone:217-793-4062
Practice Address - Fax:217-787-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0021436332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid