Provider Demographics
NPI:1104391739
Name:CENTRAL ILLINOIS CENTER FOR WELLNESS, LLC
Entity Type:Organization
Organization Name:CENTRAL ILLINOIS CENTER FOR WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-807-5356
Mailing Address - Street 1:2005 JACOBSSEN DR STE A
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6288
Mailing Address - Country:US
Mailing Address - Phone:309-807-5356
Mailing Address - Fax:309-807-5291
Practice Address - Street 1:2005 JACOBSSEN DR STE A
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6288
Practice Address - Country:US
Practice Address - Phone:309-807-5356
Practice Address - Fax:309-807-5291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care