Provider Demographics
NPI:1679226500
Name:PRAIRIE LAND THERAPEUTICS
Entity Type:Organization
Organization Name:PRAIRIE LAND THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-226-3184
Mailing Address - Street 1:70 N CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61531-1105
Mailing Address - Country:US
Mailing Address - Phone:309-226-3184
Mailing Address - Fax:
Practice Address - Street 1:70 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61531-1105
Practice Address - Country:US
Practice Address - Phone:309-226-3184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty