MEDICARE: RACHAEL RENEE DEAN DTV

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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1639687916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RACHAEL RENEE DEAN DTV

Provider Business Mailing Address
First Line	:	1943 BALDWIN RD
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-6041
Country	:	US
Telephone Number	:	217-371-9337
Fax Number	:

Provider Business Practice Location Address
First Line	:	1943 BALDWIN RD
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-6041
Country	:	US
Telephone Number	:	217-371-9337
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2018
Last Update Date	:	01/20/2018

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