Provider Demographics
NPI:1861485252
Name:LAMOINE VALLEY CLINIC, S. C.
Entity Type:Organization
Organization Name:LAMOINE VALLEY CLINIC, S. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-836-3387
Mailing Address - Street 1:5 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-3369
Mailing Address - Country:US
Mailing Address - Phone:309-836-3387
Mailing Address - Fax:309-833-1023
Practice Address - Street 1:5 DOCTORS LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3369
Practice Address - Country:US
Practice Address - Phone:309-836-3387
Practice Address - Fax:309-833-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
524240Medicare ID - Type Unspecified
IL524240Medicare UPIN