Healthcare Provider Details

I. General information

NPI: 1215529367
Provider Name (Legal Business Name): MR. CONNOR R CIMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 EAGLE CTR STE 1
O FALLON IL
62269-1945
US

IV. Provider business mailing address

404 S CARBON ST
MARION IL
62959-1318
US

V. Phone/Fax

Practice location:
  • Phone: 618-206-8816
  • Fax:
Mailing address:
  • Phone: 270-564-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: