Provider Demographics
NPI:1558947283
Name:SELECT CARE PLLC
Entity Type:Organization
Organization Name:SELECT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAESCH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:309-808-1450
Mailing Address - Street 1:2103 E WASHINGTON ST STE 2C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4365
Mailing Address - Country:US
Mailing Address - Phone:309-808-1450
Mailing Address - Fax:949-561-4829
Practice Address - Street 1:2103 E WASHINGTON ST STE 2C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-4365
Practice Address - Country:US
Practice Address - Phone:309-808-1450
Practice Address - Fax:949-561-4829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center