Provider Demographics
NPI:1255755344
Name:WABASH CHRISTIAN THERAPY AND MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:WABASH CHRISTIAN THERAPY AND MEDICAL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-732-9651
Mailing Address - Street 1:622 EMERSON RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6727
Mailing Address - Country:US
Mailing Address - Phone:217-732-9651
Mailing Address - Fax:
Practice Address - Street 1:1112 OAK ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1344
Practice Address - Country:US
Practice Address - Phone:217-732-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146730Medicare Oscar/Certification