Provider Demographics
NPI:1780863910
Name:WEST CENTRAL ALLERGY CENTER S.C.
Entity Type:Organization
Organization Name:WEST CENTRAL ALLERGY CENTER S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANILO
Authorized Official - Middle Name:GUNGON
Authorized Official - Last Name:CAPATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-685-1038
Mailing Address - Street 1:2514 W SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3825
Mailing Address - Country:US
Mailing Address - Phone:309-685-1038
Mailing Address - Fax:
Practice Address - Street 1:2514 W SCENIC DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3825
Practice Address - Country:US
Practice Address - Phone:309-685-1038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-02-05
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
IL0007232040OtherBLUE CROSS BLUE SHIELD
ILCM5516Medicare PIN
IL211613Medicare PIN