Provider Demographics
NPI:1336258540
Name:SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER
Entity Type:Organization
Organization Name:SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-874-3120
Mailing Address - Street 1:1736 KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2134
Mailing Address - Country:US
Mailing Address - Phone:618-874-3120
Mailing Address - Fax:618-215-4048
Practice Address - Street 1:1736 KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62204-2134
Practice Address - Country:US
Practice Address - Phone:618-874-3120
Practice Address - Fax:618-215-4048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141956Medicare Oscar/Certification
IL141923Medicare Oscar/Certification
IL992400Medicare PIN