Provider Demographics
NPI:1437290798
Name:FAMILY HEALTH CLINIC
Entity Type:Organization
Organization Name:FAMILY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:618-665-4612
Mailing Address - Street 1:134 S. CHURCH ST.
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62858
Mailing Address - Country:US
Mailing Address - Phone:618-665-4612
Mailing Address - Fax:
Practice Address - Street 1:134 S. CHURCH ST.
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:IL
Practice Address - Zip Code:62858
Practice Address - Country:US
Practice Address - Phone:618-665-4612
Practice Address - Fax:618-665-4610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL742975504001Medicaid
148928Medicare ID - Type Unspecified