Provider Demographics
NPI:1659811073
Name:PRIMARY HEALTH & NUTRITION SERVICES INC.
Entity Type:Organization
Organization Name:PRIMARY HEALTH & NUTRITION SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:RNCDDN
Authorized Official - Phone:815-546-9496
Mailing Address - Street 1:514 COTTONWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1010
Mailing Address - Country:US
Mailing Address - Phone:815-546-9496
Mailing Address - Fax:815-469-4136
Practice Address - Street 1:514 COTTONWOOD RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1010
Practice Address - Country:US
Practice Address - Phone:815-546-9496
Practice Address - Fax:815-469-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-04
Last Update Date:2017-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-249653163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL360-62-0745-001Medicaid