Provider Demographics
NPI:1598866386
Name:STAUNTON CLINIC, LLC
Entity Type:Organization
Organization Name:STAUNTON CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DOBRINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-635-3800
Mailing Address - Street 1:444 N EDWARDSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1334
Mailing Address - Country:US
Mailing Address - Phone:618-635-3800
Mailing Address - Fax:618-635-3952
Practice Address - Street 1:444 N EDWARDSVILLE ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1334
Practice Address - Country:US
Practice Address - Phone:618-635-3800
Practice Address - Fax:618-635-3952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL001261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL148974Medicare Oscar/Certification
ILDD4278Medicare PIN
ILH27194Medicare UPIN
ILF86407Medicare UPIN
ILH66430Medicare UPIN
IL=========001Medicaid