Healthcare Provider Details

I. General information

NPI: 1003967704
Provider Name (Legal Business Name): LIMINA INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 E JEFFERSON ST
BLOOMINGTON IL
61701
US

IV. Provider business mailing address

903 E JEFFERSON ST
BLOOMINGTON IL
61701
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-1414
  • Fax: 309-827-0885
Mailing address:
  • Phone: 309-828-1414
  • Fax: 309-827-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. SCOTT MASON OLBERT
Title or Position: PRESIDENT LIMINA INSTITUTE
Credential: MDIV
Phone: 309-828-1414