Healthcare Provider Details

I. General information

NPI: 1871208074
Provider Name (Legal Business Name): FAMILIA FIRST HEALTH NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 07/22/2024
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S STATE ST SUITE B
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

PO BOX 2403
CHAMPAIGN IL
61825
US

V. Phone/Fax

Practice location:
  • Phone: 217-721-5080
  • Fax:
Mailing address:
  • Phone: 772-559-5878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CARRIE KEENAN
Title or Position: COO
Credential: PA-C
Phone: 217-637-1310