Provider Demographics
NPI:1679753123
Name:JENECSIS CASTRO-SKOGLUND SC
Entity Type:Organization
Organization Name:JENECSIS CASTRO-SKOGLUND SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENECSIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTRO-SKOGLUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-689-8370
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-8370
Mailing Address - Fax:309-689-8380
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 114
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-689-8370
Practice Address - Fax:309-689-8380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207156Medicare PIN