Healthcare Provider Details

I. General information

NPI: 1568580843
Provider Name (Legal Business Name): CEVENE CARE CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6451 E RIVERSIDE BLVD #103
ROCKFORD IL
61114-4421
US

IV. Provider business mailing address

6451 E RIVERSIDE BLVD #103
ROCKFORD IL
61114-4421
US

V. Phone/Fax

Practice location:
  • Phone: 815-639-9900
  • Fax: 815-639-9860
Mailing address:
  • Phone: 815-639-9900
  • Fax: 815-639-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number149009052
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number038009573
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number336045953
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036118972
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number31602516
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005320
License Number StateIL
# 7
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0070009799
License Number StateIL
# 8
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009573
License Number StateIL

VIII. Authorized Official

Name: DR. ANGELA RUF
Title or Position: MANAGER
Credential:
Phone: 815-639-9900