Provider Demographics
NPI:1326293135
Name:MCLANE BRIAN, LLC
Entity Type:Organization
Organization Name:MCLANE BRIAN, LLC
Other - Org Name:FAMILY FIRST HOMECARE OF SOUTHERN ILLINOIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:EMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-850-0042
Mailing Address - Street 1:2203 N LOIS AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-2387
Mailing Address - Country:US
Mailing Address - Phone:813-850-0042
Mailing Address - Fax:813-850-0043
Practice Address - Street 1:1999 WABASH AVE STE 204
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-5374
Practice Address - Country:US
Practice Address - Phone:008-853-5292
Practice Address - Fax:855-830-5482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care