MEDICARE: SOUTHERN IL REGIONAL WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1336258540	OTHER	IL	NPI

General Provider Information

NPI Number	:	1295194009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN IL REGIONAL WELLNESS CENTER

Provider Business Mailing Address
First Line	:	1736 KINGSHIGHWAY
Second Line	:
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:	618-215-4048

Provider Business Practice Location Address
First Line	:	1736 KINGSHIGHWAY
Second Line	:
City	:	WASHINGTON PARK
State	:	IL
Zip	:	62204-2135
Country	:	US
Telephone Number	:	618-482-7922
Fax Number	:	618-215-4048

Authorized Official
Title or Position	:	CEO
Name	:	MARK FREELAND
Credential	:
Telephone Number	:	618-482-7922

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	05/24/2016

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Directions to “SOUTHERN IL REGIONAL WELLNESS CENTER ” Practice Location

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