Healthcare Provider Details

I. General information

NPI: 1881998102
Provider Name (Legal Business Name): MARK WAYNE MCCLINTOCK BCHIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2010
Last Update Date: 12/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 GENERAL ELECTRIC RD STE 1
BLOOMINGTON IL
61704-4193
US

IV. Provider business mailing address

3801 GE RD STE 1
BLOOMINGTON IL
61704-4193
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-9552
  • Fax: 309-662-9377
Mailing address:
  • Phone: 309-662-9552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number037-0365
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: