Provider Demographics
NPI:1760729925
Name:CENTER FOR FAMILY HEALTH - MALTA
Entity Type:Organization
Organization Name:CENTER FOR FAMILY HEALTH - MALTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-752-3253
Mailing Address - Street 1:21193 MALTA RD
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:IL
Mailing Address - Zip Code:60150-9600
Mailing Address - Country:US
Mailing Address - Phone:815-752-3253
Mailing Address - Fax:
Practice Address - Street 1:21193 MALTA RD
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:IL
Practice Address - Zip Code:60150-9600
Practice Address - Country:US
Practice Address - Phone:815-752-3253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTER FOR FAMILY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-08
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8579Medicare PIN