Healthcare Provider Details

I. General information

NPI: 1669616983
Provider Name (Legal Business Name): ILLINOIS STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 S UNIVERSITY ST CAMPUS BOX 4720
NORMAL IL
61790-4720
US

IV. Provider business mailing address

275 S UNIVERSITY ST CAMPUS BOX 4720
NORMAL IL
61790-4720
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-8641
  • Fax: 309-438-0575
Mailing address:
  • Phone: 309-438-8641
  • Fax: 309-438-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEIDI VERTICCHIO
Title or Position: CLINIC DIRECTOR
Credential:
Phone: 309-438-3266