Healthcare Provider Details

I. General information

NPI: 1336689322
Provider Name (Legal Business Name): ST. JOHN'S LUTHERAN CHURCH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 06/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 N. LAKE RD.
LENA IL
61048-8712
US

IV. Provider business mailing address

311 N. LAKE R. P. O BOX 172
LENA IL
61048-8712
US

V. Phone/Fax

Practice location:
  • Phone: 815-369-2690
  • Fax: 815-369-2535
Mailing address:
  • Phone: 815-369-2690
  • Fax: 815-369-2535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. FAWN NOLAN
Title or Position: CHAIRMAN OF THE BOARD
Credential:
Phone: 815-369-4035