Healthcare Provider Details

I. General information

NPI: 1720736002
Provider Name (Legal Business Name): DECATUR ORTHOPEDIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E ASHLAND AVE
MT ZION IL
62549-1271
US

IV. Provider business mailing address

104 E ASHLAND AVE
MT ZION IL
62549-1271
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-2665
  • Fax:
Mailing address:
  • Phone: 217-864-2665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: KRISTIN E SAMS
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 217-864-2665