Healthcare Provider Details

I. General information

NPI: 1619888591
Provider Name (Legal Business Name): MIDWEST AGRICULTURAL WELLNESS INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 E DEYOUNG ST
MARION IL
62959-5013
US

IV. Provider business mailing address

595 BARTER RD SALINE COUNTY
HARRISBURG IL
62946-4102
US

V. Phone/Fax

Practice location:
  • Phone: 618-579-4716
  • Fax:
Mailing address:
  • Phone: 618-579-4716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TINA MARTIN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-579-4716