Healthcare Provider Details

I. General information

NPI: 1205777109
Provider Name (Legal Business Name): CHAMPAIGN INTEGRATIVE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7673
US

IV. Provider business mailing address

3115 VILLAGE OFFICE PL
CHAMPAIGN IL
61822-7673
US

V. Phone/Fax

Practice location:
  • Phone: 217-531-4101
  • Fax:
Mailing address:
  • Phone: 217-531-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TED NEMECZ
Title or Position: CFO
Credential:
Phone: 217-637-5171