Provider Demographics
NPI:1881835577
Name:CENTER FOR HEALTH RENEWAL AND LONGEVITY LLC
Entity Type:Organization
Organization Name:CENTER FOR HEALTH RENEWAL AND LONGEVITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-784-2364
Mailing Address - Street 1:201 W SPRINGFIELD AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-4834
Mailing Address - Country:US
Mailing Address - Phone:217-955-9554
Mailing Address - Fax:
Practice Address - Street 1:201 W SPRINGFIELD AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-4834
Practice Address - Country:US
Practice Address - Phone:217-955-9554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-10
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002058261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE14580Medicare UPIN
ILQ49702Medicare UPIN