=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558947283
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SELECT CARE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2021
-----------------------------------------------------
Last Update Date | 03/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2103 E WASHINGTON ST STE 2C
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-808-1450
-----------------------------------------------------
Fax | 949-561-4829
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2103 E WASHINGTON ST STE 2C
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-808-1450
-----------------------------------------------------
Fax | 949-561-4829
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHANNON LAESCH
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 309-808-1450
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------