Healthcare Provider Details

I. General information

NPI: 1679626550
Provider Name (Legal Business Name): WARREN G MURRAY DEVELOPMENTAL CTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 W MCCORD ST
CENTRALIA IL
62801-5805
US

IV. Provider business mailing address

1535 W MCCORD ST
CENTRALIA IL
62801-5805
US

V. Phone/Fax

Practice location:
  • Phone: 618-532-1911
  • Fax: 618-532-7464
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number059005407
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number054017317
License Number StateIL

VIII. Authorized Official

Name: TARA TIMMONS
Title or Position: PHARMACY MGR
Credential: PHARM D
Phone: 618-532-1811