Healthcare Provider Details

I. General information

NPI: 1104144187
Provider Name (Legal Business Name): CHESTER CLINIC PROFESSIONAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 07/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 W SHAWNEETOWN TRL
STEELEVILLE IL
62288-1126
US

IV. Provider business mailing address

602 W SHAWNEETOWN TRL
STEELEVILLE IL
62288-1126
US

V. Phone/Fax

Practice location:
  • Phone: 618-965-3382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DONNA MARTIN
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 618-965-3382