Healthcare Provider Details

I. General information

NPI: 1386950764
Provider Name (Legal Business Name): SPRINGFIELD ELDER CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2010
Last Update Date: 08/24/2010
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

1808 S BATES AVE
SPRINGFIELD IL
62704-3354
US

V. Phone/Fax

Practice location:
  • Phone: 217-741-4304
  • Fax:
Mailing address:
  • Phone: 217-741-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209006847
License Number StateIL

VIII. Authorized Official

Name: MS. ELIZABETH DIANNE CARLSON
Title or Position: OWNER
Credential: PH.D, MPH, BSN
Phone: 217-741-4304