Provider Demographics
NPI:1629444070
Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Other - Org Name:TAZWOOD CENTER FOR WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:N
Authorized Official - Middle Name:BRENDA
Authorized Official - Last Name:FRANKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-477-5526
Mailing Address - Street 1:210 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-2444
Mailing Address - Country:US
Mailing Address - Phone:309-647-5240
Mailing Address - Fax:
Practice Address - Street 1:210 W. WALNUT STREET
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAZWOOD MENTAL HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04132251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL949000Medicare PIN