Provider Demographics
NPI:1740596394
Name:WNUCARE
Entity Type:Organization
Organization Name:WNUCARE
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIETETIC TECHNITION REGISTERED NUTR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DTR
Authorized Official - Phone:618-410-4236
Mailing Address - Street 1:1020 APT A ALTON POINT CIRCLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5280
Mailing Address - Country:US
Mailing Address - Phone:618-410-4236
Mailing Address - Fax:161-833-9090
Practice Address - Street 1:301 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5280
Practice Address - Country:US
Practice Address - Phone:618-470-4236
Practice Address - Fax:618-433-9090
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL302R00000X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5533PHILMedicaid