Provider Demographics
NPI:1760508907
Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Other - Org Name:TMHC EP MH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:MINGUS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-347-5579
Mailing Address - Street 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6257
Mailing Address - Country:US
Mailing Address - Phone:309-347-5579
Mailing Address - Fax:309-347-4264
Practice Address - Street 1:111 W. WASHINGTON STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611
Practice Address - Country:US
Practice Address - Phone:309-694-6462
Practice Address - Fax:309-694-7812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL949000Medicare ID - Type Unspecified