=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922114800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPARTA COMMUNITY HOSPITAL D/B/A QUALITY HEALTHCARE CLINICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 05/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 N BORDERS AVE STE C
-----------------------------------------------------
City | MARISSA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62257-1195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-295-1591
-----------------------------------------------------
Fax | 618-295-1473
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 297
-----------------------------------------------------
City | SPARTA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62286-0297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-443-1337
-----------------------------------------------------
Fax | 618-443-1383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MRS. LISA ERNSTING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-433-2177
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------