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General NPI Number Information
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NPI Number | 1659531549
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Entity Type | Organization
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Legal Business Name | CLINIC OF PSYCHIATRIC CARE
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Dates
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Enumeration Date | 06/13/2008
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 1752 WINDSOR RD STE 203
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City | LOVES PARK
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State | IL
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Zip | 61111-4280
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Country | US
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Telephone | 815-986-2620
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Fax |
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Provider Business Mailing Address
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Address Line | 1752 WINDSOR RD
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City | LOVES PARK
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State | IL
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Zip | 61111-4280
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Country | US
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Telephone | 815-986-2620
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING AGENT
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Name | PETER SMITH
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Credential |
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Telephone | 815-965-8505
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036076824
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License Number State | IL
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