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General NPI Number Information
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NPI Number | 1215944152
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Entity Type | Organization
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Legal Business Name | FAMILY HEALTHCARE CLINIC & REHAB
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Dates
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Enumeration Date | 08/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 701 N COMMERCIAL ST SUITE 4
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City | HARRISBURG
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State | IL
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Zip | 62946-3335
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Country | US
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Telephone | 618-253-8863
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Fax | 618-253-8864
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Provider Business Mailing Address
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Address Line | 701 N COMMERCIAL ST SUITE 4
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City | HARRISBURG
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State | IL
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Zip | 62946-3335
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Country | US
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Telephone | 618-253-8863
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Fax | 618-253-8864
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Authorized Official
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Title or Position | PRESIDENT/AGENT
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Name | AUGUSTINE EBONG
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Credential |
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Telephone | 618-253-8863
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 148973
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License Number State | IL
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