Healthcare Provider Details

I. General information

NPI: 1083192165
Provider Name (Legal Business Name): ADVANCED HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 PINTAIL DR STE A
SPRINGFIELD IL
62711-7380
US

IV. Provider business mailing address

1749 W GOLF RD # 279
MOUNT PROSPECT IL
60056-4025
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-6959
  • Fax:
Mailing address:
  • Phone: 630-310-0095
  • Fax:

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
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: CRISTINA CAOILI AGNO
Title or Position: ADMINISTRATOR
Credential:
Phone: 217-726-6956