Provider Demographics
NPI:1891082194
Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Other - Org Name:CRUSADER COMMUNITY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-490-1737
Mailing Address - Street 1:6115 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4155
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1845
Practice Address - Street 1:6115 N 2ND ST
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-4155
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1625
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRUSADER CENTRAL CLINIC ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-07
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)