Healthcare Provider Details

I. General information

NPI: 1124316286
Provider Name (Legal Business Name): SPRINGFIELD ELDER CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 07/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 S BATES AVE
SPRINGFIELD IL
62704-3354
US

IV. Provider business mailing address

PO BOX 431
STILWELL KS
66085-0431
US

V. Phone/Fax

Practice location:
  • Phone: 217-391-6301
  • Fax: 713-344-9420
Mailing address:
  • Phone: 217-391-6301
  • Fax: 713-344-9420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPN209006847
License Number StateIL

VIII. Authorized Official

Name: DR. ELIZABETH CARLSON
Title or Position: OWNER
Credential: APRN
Phone: 217-391-6301