Provider Demographics
NPI:1659733699
Name:COMWELL
Entity Type:Organization
Organization Name:COMWELL
Other - Org Name:HUMAN SERVICE CENTER OF S METRO E
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KIMBER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-282-6233
Mailing Address - Street 1:10257 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4418
Mailing Address - Country:US
Mailing Address - Phone:618-282-6233
Mailing Address - Fax:618-282-6220
Practice Address - Street 1:109 W MILL STREET
Practice Address - Street 2:
Practice Address - City:OKAWVILLE
Practice Address - State:IL
Practice Address - Zip Code:62271-4418
Practice Address - Country:US
Practice Address - Phone:618-241-2091
Practice Address - Fax:618-241-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-28
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0280-0005-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========023Medicaid