Provider Demographics
NPI:1770905952
Name:CHARLESTON PRIMARY CARE INC.
Entity type:Organization
Organization Name:CHARLESTON PRIMARY CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APN, NP-C
Authorized Official - Phone:217-276-6421
Mailing Address - Street 1:506 W LINCOLN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-2453
Mailing Address - Country:US
Mailing Address - Phone:217-348-8730
Mailing Address - Fax:217-345-7146
Practice Address - Street 1:506 W LINCOLN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-2453
Practice Address - Country:US
Practice Address - Phone:217-348-8730
Practice Address - Fax:217-345-7146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care