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General NPI Number Information
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NPI Number | 1033408356
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Entity Type | Organization
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Legal Business Name | GALENA CLINIC, INC.
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 01/04/2018
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Provider Practice Location Address
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Address Line | 939 GALENA SQUARE DR
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City | GALENA
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State | IL
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Zip | 61036-1355
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Country | US
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Telephone | 815-777-1300
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Fax | 815-777-1308
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Provider Business Mailing Address
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Address Line | 939 GALENA SQUARE DR
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City | GALENA
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State | IL
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Zip | 61036-1355
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Country | US
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Telephone | 815-777-1300
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH P DAVIS
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Credential | MD
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Telephone | 815-777-1300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | A-6258-0001-A
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | A-6258-0001-A
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License Number State | IL
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