Healthcare Provider Details

I. General information

NPI: 1730219627
Provider Name (Legal Business Name): CARLE CLINIC ASSOCIATION, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 GREEN APPLE LANE
MONTICELLO IL
61856-1175
US

IV. Provider business mailing address

4000 GREEN APPLE LANE
MONTICELLO IL
61856-1175
US

V. Phone/Fax

Practice location:
  • Phone: 217-762-2518
  • Fax:
Mailing address:
  • Phone: 217-762-2518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number060009052
License Number StateIL

VIII. Authorized Official

Name: KIRK MOBERG
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 217-383-3311