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General NPI Number Information
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NPI Number | 1407199391
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Entity Type | Organization
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Legal Business Name | PROMISE HEALTHCARE NFP
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Dates
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Enumeration Date | 03/29/2013
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 819 BLOOMINGTON RD
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone | 217-356-1558
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Fax |
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Provider Business Mailing Address
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Address Line | 819 BLOOMINGTON RD
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City | CHAMPAIGN
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State | IL
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Zip | 61820-2101
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Country | US
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Telephone | 217-356-1558
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Fax |
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Authorized Official
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Title or Position | CFO
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Name | JENNIFER HENRY
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Credential |
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Telephone | 217-403-5401
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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