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General NPI Number Information
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NPI Number | 1871345165
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Entity Type | Organization
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Legal Business Name | LONG CREEK MEDICAL LLC
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Dates
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Enumeration Date | 04/02/2024
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Last Update Date | 11/26/2025
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Provider Practice Location Address
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Address Line | 2550 S 70TH ST
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City | DECATUR
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State | IL
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Zip | 62521-8742
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Country | US
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Telephone | 217-330-0407
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Fax |
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Provider Business Mailing Address
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Address Line | 2550 S 70TH ST
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City | DECATUR
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State | IL
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Zip | 62521-8742
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Country | US
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Telephone | 217-330-0407
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Fax | 217-864-1033
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER SHAWN MAHANNAH
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Credential | APN
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Telephone | 217-519-3203
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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