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1376492306 NPI number — CENTRAL ILLINOIS FRIENDS OF PWA, INC.

NPI Number: 1376492306
Health Care Provider/Practitioner: CENTRAL ILLINOIS FRIENDS OF PWA, INC.

Information about “1376492306” NPI (CENTRAL ILLINOIS FRIENDS OF PWA, INC.) exists in 1376492306 in HTML format HTML  |  1376492306 in plain Text format TXT  |  1376492306 in PDF (Portable Document Format) PDF  |  1376492306 in an XML format XML  formats.

NPI Number : 1376492306 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1376492306",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "CENTRAL ILLINOIS FRIENDS OF PWA, INC.",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "PO BOX 5022",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "PEORIA",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "61601-5022",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "309-431-5880",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "120 NE GLEN OAK AVE STE 201",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "PEORIA",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "61603-4315",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "309-431-5880",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "01/23/2026",
    "LastUpdateDate": "01/23/2026",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "KIMLER",
    "AuthorizedOfficialFirstName": "DERIC",
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": "EXECUTIVE DIRECTOR",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": "309-431-5880",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "261QC1500X",
          "TaxonomyName": "Community Health Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "363LC1500X",
          "TaxonomyName": "Community Health Nurse Practitioner",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
      }
    }
  }
}
                
            

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