Healthcare Provider Details

I. General information

NPI: 1881746097
Provider Name (Legal Business Name): WEST CENTRAL ILLINOIS THERAPY & SPORTS MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W WASHINGTON ST
PITTSFIELD IL
62363-1441
US

IV. Provider business mailing address

1025 MAINE ST
QUINCY IL
62301-4038
US

V. Phone/Fax

Practice location:
  • Phone: 217-285-4512
  • Fax: 217-285-5740
Mailing address:
  • Phone: 217-222-6550
  • Fax: 217-277-2253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. DAN EVANS
Title or Position: CHAIRMAN OF THE BOARD
Credential: MD
Phone: 217-222-6550