MEDICARE: CLS MEDICAL INC.

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1790980985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLS MEDICAL INC.

Provider Business Mailing Address
First Line	:	PO BOX 40
Second Line	:	200 SOUTH BROADWAY STREET
City	:	GOREVILLE
State	:	IL
Zip	:	62939-0040
Country	:	US
Telephone Number	:	618-995-2396
Fax Number	:	618-995-2947

Provider Business Practice Location Address
First Line	:	200 S BROADWAY
Second Line	:
City	:	GOREVILLE
State	:	IL
Zip	:	62939-2447
Country	:	US
Telephone Number	:	618-995-2396
Fax Number	:	618-995-2947

Authorized Official
Title or Position	:	OWNER CEO
Name	:	CRYSTAL L STANGLE
Credential	:	MSHED CEO
Telephone Number	:	618-995-2396

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	08/22/2020

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Directions to “CLS MEDICAL INC. ” Practice Location

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