Healthcare Provider Details

I. General information

NPI: 1457044919
Provider Name (Legal Business Name): MACON RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 HUBBARD AVE
DECATUR IL
62526-2876
US

IV. Provider business mailing address

2121 HUBBARD AVE
DECATUR IL
62526-2876
US

V. Phone/Fax

Practice location:
  • Phone: 217-872-5380
  • Fax:
Mailing address:
  • Phone: 217-872-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRISCILLA MAXWELL
Title or Position: DIRECTOR OF BEHAVIORAL HEALTH
Credential:
Phone: 217-872-5380