Healthcare Provider Details

I. General information

NPI: 1871286393
Provider Name (Legal Business Name): FROILAN V PERUCHO APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 OLD JACKSONVILLE RD STE 200
SPRINGFIELD IL
62704-7401
US

IV. Provider business mailing address

3132 OLD JACKSONVILLE RD STE 200
SPRINGFIELD IL
62704-7401
US

V. Phone/Fax

Practice location:
  • Phone: 217-862-0800
  • Fax: 217-862-0202
Mailing address:
  • Phone: 217-862-0800
  • Fax: 217-862-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027551
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: