Healthcare Provider Details

I. General information

NPI: 1649593807
Provider Name (Legal Business Name): ELLEN LISTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14094 KENNEDY DR
SOUTH BELOIT IL
61080-2502
US

IV. Provider business mailing address

14094 KENNEDY DR
SOUTH BELOIT IL
61080-2502
US

V. Phone/Fax

Practice location:
  • Phone: 815-601-4055
  • Fax:
Mailing address:
  • Phone: 815-601-4055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number108005-030
License Number StateWI

VIII. Authorized Official

Name: ELLEN LISTING
Title or Position: RN
Credential:
Phone: 815-601-4055