Healthcare Provider Details

I. General information

NPI: 1356596563
Provider Name (Legal Business Name): CHESTNUT HEALTH SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2008
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

IV. Provider business mailing address

1003 MARTIN LUTHER KING DR
BLOOMINGTON IL
61701-1429
US

V. Phone/Fax

Practice location:
  • Phone: 309-827-6026
  • Fax:
Mailing address:
  • Phone: 309-827-6026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA-0126-0002-A
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA COOPER
Title or Position: MANAGED CARE SUPERVISOR
Credential: LPN
Phone: 309-820-3535