Healthcare Provider Details

I. General information

NPI: 1780852244
Provider Name (Legal Business Name): CRUSADERS CENTRAL CLINIC ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2008
Last Update Date: 08/24/2022
Certification Date: 08/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 LOGAN AVE
BELVIDERE IL
61008-3966
US

IV. Provider business mailing address

1050 LOGAN AVE
BELVIDERE IL
61008-3966
US

V. Phone/Fax

Practice location:
  • Phone: 815-547-0282
  • Fax: 815-490-1625
Mailing address:
  • Phone: 815-490-1600
  • Fax: 815-490-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SAMUEL MILLER
Title or Position: PRESIDENT & CEO
Credential:
Phone: 815-490-1737