Healthcare Provider Details

I. General information

NPI: 1609027713
Provider Name (Legal Business Name): LENA WINSLOW 202
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 FREMONT ST
LENA IL
61048-8610
US

IV. Provider business mailing address

401 FREMONT ST
LENA IL
61048-8610
US

V. Phone/Fax

Practice location:
  • Phone: 815-369-2525
  • Fax:
Mailing address:
  • Phone: 815-369-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: AMY LIEB
Title or Position: FINANCIAL ADMINISTRATOR
Credential:
Phone: 815-369-3102