Healthcare Provider Details

I. General information

NPI: 1033408356
Provider Name (Legal Business Name): GALENA CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 GALENA SQUARE DR
GALENA IL
61036-1355
US

IV. Provider business mailing address

939 GALENA SQUARE DR
GALENA IL
61036-1355
US

V. Phone/Fax

Practice location:
  • Phone: 815-777-1300
  • Fax: 815-777-1308
Mailing address:
  • Phone: 815-777-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberA-6258-0001-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA-6258-0001-A
License Number StateIL

VIII. Authorized Official

Name: DR. KENNETH P DAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 815-777-1300