Provider Demographics
NPI:1407199391
Name:PROMISE HEALTHCARE NFP
Entity Type:Organization
Organization Name:PROMISE HEALTHCARE NFP
Other - Org Name:FRANCES NELSON DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-403-5401
Mailing Address - Street 1:819 BLOOMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-2101
Mailing Address - Country:US
Mailing Address - Phone:217-356-1558
Mailing Address - Fax:
Practice Address - Street 1:819 BLOOMINGTON RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-356-1558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANCES NELSON HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-29
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental