Healthcare Provider Details

I. General information

NPI: 1720791437
Provider Name (Legal Business Name): RASSIK COMPLETE RECOVERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 CEDAR CT
CARBONDALE IL
62901-5333
US

IV. Provider business mailing address

1155 CEDAR CT
CARBONDALE IL
62901-5333
US

V. Phone/Fax

Practice location:
  • Phone: 618-490-1045
  • Fax: 618-319-1279
Mailing address:
  • Phone: 618-490-1045
  • Fax: 618-319-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ANITA CHANDRA
Title or Position: VICE PRESIDENT
Credential:
Phone: 618-303-5360