Healthcare Provider Details

I. General information

NPI: 1801885504
Provider Name (Legal Business Name): HEALTH VENTURES OF SOUTHERN ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 REGENCY PLAZA DR
COLLINSVILLE IL
62234-6114
US

IV. Provider business mailing address

1 REGENCY PLAZA DR
COLLINSVILLE IL
62234-6114
US

V. Phone/Fax

Practice location:
  • Phone: 618-343-0640
  • Fax: 618-343-0684
Mailing address:
  • Phone: 618-343-0640
  • Fax: 618-343-0684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWARD HUGHES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-343-0639