Healthcare Provider Details

I. General information

NPI: 1669752960
Provider Name (Legal Business Name): IMMANUEL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2011
Last Update Date: 08/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S MORRIS AVE SUITE A
BLOOMINGTON IL
61701-4884
US

IV. Provider business mailing address

PO BOX 3281
BLOOMINGTON IL
61702-3281
US

V. Phone/Fax

Practice location:
  • Phone: 309-824-7485
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TRINA SCOTT
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D.
Phone: 309-824-7485