Healthcare Provider Details

I. General information

NPI: 1558947283
Provider Name (Legal Business Name): SELECT CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 E WASHINGTON ST STE 2C
BLOOMINGTON IL
61701-4365
US

IV. Provider business mailing address

2103 E WASHINGTON ST STE 2C
BLOOMINGTON IL
61701-4365
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-1450
  • Fax: 949-561-4829
Mailing address:
  • Phone: 309-808-1450
  • Fax: 949-561-4829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANNON LAESCH
Title or Position: OWNER
Credential: APRN
Phone: 309-808-1450