Healthcare Provider Details

I. General information

NPI: 1982955712
Provider Name (Legal Business Name): NATIONAL HEALTHCARE OF MT VERNON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 W WASHINGTON ST STE A
BENTON IL
62812
US

IV. Provider business mailing address

PO BOX 689022
FRANKLIN TN
37068-9022
US

V. Phone/Fax

Practice location:
  • Phone: 618-435-2229
  • Fax:
Mailing address:
  • Phone: 800-709-7338
  • Fax: 615-469-6505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number0003947
License Number StateIL

VIII. Authorized Official

Name: TARA P RICHARDSON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 615-221-3672