Provider Demographics
NPI:1841970068
Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Entity type:Organization
Organization Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PEGGYANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-490-1616
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1834
Practice Address - Street 1:1100 BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1429
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1834
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRUSADERS CENTRAL CLINIC ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-07-21
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty