Provider Demographics
NPI:1073902342
Name:CONVENIENT MEDICAL CARE CLINIC LLC
Entity Type:Organization
Organization Name:CONVENIENT MEDICAL CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:618-923-4310
Mailing Address - Street 1:1403 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-1918
Mailing Address - Country:US
Mailing Address - Phone:618-923-4310
Mailing Address - Fax:
Practice Address - Street 1:29 CIRCLE ST
Practice Address - Street 2:ZEIGLER
Practice Address - City:ZEIGLER
Practice Address - State:IL
Practice Address - Zip Code:62999-1148
Practice Address - Country:US
Practice Address - Phone:618-923-4310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001210261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care