Healthcare Provider Details

I. General information

NPI: 1699832683
Provider Name (Legal Business Name): POOLSIDE HEALTH & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3733 POOLSIDE DR
DANVILLE IL
61832-1144
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-446-9283
  • Fax: 217-442-2181
Mailing address:
  • Phone: 217-326-2911
  • Fax: 217-344-8047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number13304532
License Number StateIL

VIII. Authorized Official

Name: MS. PATRICIA A OWENS
Title or Position: DIRECTOR OF PATIENT ACCOUNTING
Credential:
Phone: 217-326-2911