Provider Demographics
NPI:1790980985
Name:CLS MEDICAL INC.
Entity Type:Organization
Organization Name:CLS MEDICAL INC.
Other - Org Name:GOREVILLE FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:STANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MSHED CEO
Authorized Official - Phone:618-995-2396
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:200 SOUTH BROADWAY STREET
Mailing Address - City:GOREVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62939-0040
Mailing Address - Country:US
Mailing Address - Phone:618-995-2396
Mailing Address - Fax:618-995-2947
Practice Address - Street 1:200 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GOREVILLE
Practice Address - State:IL
Practice Address - Zip Code:62939-2447
Practice Address - Country:US
Practice Address - Phone:618-995-2396
Practice Address - Fax:618-995-2947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care