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General NPI Number Information
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NPI Number | 1306349576
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Entity Type | Organization
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Legal Business Name | CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
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Dates
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Enumeration Date | 03/14/2018
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 2426 W CORNERSTONE CT STE 100
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City | PEORIA
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State | IL
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Zip | 61614-2400
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Country | US
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Telephone | 309-966-3137
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Fax |
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Provider Business Mailing Address
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Address Line | 400 CIMMERON DR
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City | EAST PEORIA
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State | IL
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Zip | 61611-7505
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Country | US
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Telephone | 309-696-9010
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LARRY F OVERCASH
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Credential | MD
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Telephone | 309-696-9010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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