Healthcare Provider Details

I. General information

NPI: 1720453202
Provider Name (Legal Business Name): STREATOR CHIDLRENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 SPRING ST FL 5
STREATOR IL
61364-3332
US

IV. Provider business mailing address

111 SPRING ST FL 5
STREATOR IL
61364-3332
US

V. Phone/Fax

Practice location:
  • Phone: 815-673-2353
  • Fax: 815-673-2486
Mailing address:
  • Phone: 815-673-2353
  • Fax: 815-673-2486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036091951
License Number StateIL

VIII. Authorized Official

Name: MS. KEADY GILLMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 815-673-2353