Provider Demographics
NPI:1568580843
Name:CEVENE CARE CLINIC, INC
Entity Type:Organization
Organization Name:CEVENE CARE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-639-9900
Mailing Address - Street 1:6451 E RIVERSIDE BLVD
Mailing Address - Street 2:#103
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-4421
Mailing Address - Country:US
Mailing Address - Phone:815-639-9900
Mailing Address - Fax:815-639-9860
Practice Address - Street 1:6451 E RIVERSIDE BLVD
Practice Address - Street 2:#103
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4421
Practice Address - Country:US
Practice Address - Phone:815-639-9900
Practice Address - Fax:815-639-9860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149009052104100000X
IL038009573111N00000X, 111NR0400X
IL336045953207LP2900X
IL036118972208D00000X
IL31602516213E00000X
IL016005320213ES0103X
IL0070009799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210693OtherMEDICARE GROUP #
IL210693OtherMEDICARE GROUP #