Healthcare Provider Details

I. General information

NPI: 1063538940
Provider Name (Legal Business Name): JOAN K SELBURG CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 NE GLEN OAK AVE SUITE 407
PEORIA IL
61603-4301
US

IV. Provider business mailing address

120 NE GLEN OAK AVE SUITE 407
PEORIA IL
61603-4301
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5975
  • Fax: 309-655-1678
Mailing address:
  • Phone: 309-672-5975
  • Fax: 309-655-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number102326
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: