Provider Demographics
NPI:1174356471
Name:COMWELL
Entity type:Organization
Organization Name:COMWELL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNER
Authorized Official - Suffix:
Authorized Official - Credentials:AM
Authorized Official - Phone:618-282-6233
Mailing Address - Street 1:10257 STATE ROUTE 3
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-4418
Mailing Address - Country:US
Mailing Address - Phone:618-282-6233
Mailing Address - Fax:
Practice Address - Street 1:207 N JAMES ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286-1213
Practice Address - Country:US
Practice Address - Phone:618-282-6233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities