Provider Demographics
NPI:1265588776
Name:SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-874-3120
Mailing Address - Street 1:1835 KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:62204-2135
Mailing Address - Country:US
Mailing Address - Phone:618-482-7922
Mailing Address - Fax:618-482-7881
Practice Address - Street 1:1835 KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON PARK
Practice Address - State:IL
Practice Address - Zip Code:62204-2135
Practice Address - Country:US
Practice Address - Phone:618-482-7922
Practice Address - Fax:618-482-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid