Healthcare Provider Details

I. General information

NPI: 1043851488
Provider Name (Legal Business Name): WEST CENTRAL ILLINOIS NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 YORK ST. ROOM 333
QUINCY IL
62301
US

IV. Provider business mailing address

639 YORK ST. ROOM 333
QUINCY IL
62301
US

V. Phone/Fax

Practice location:
  • Phone: 217-592-3657
  • Fax: 217-592-3761
Mailing address:
  • Phone: 217-592-3657
  • Fax: 217-592-3761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY J THOMPSON
Title or Position: DIRECTOR
Credential: CDM/CFPP
Phone: 217-592-3653