Organization
SOUTHERN IL REGIONAL WELLNESS CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MARK FREELAND (CEO)
(618) 482-7922
Entity
Organization
Contact information
Practice address
1736 KINGSHIGHWAY, WASHINGTON PARK, IL 62204-2135
(618) 482-7922
(618) 215-4048
Mailing address
1736 KINGSHIGHWAY, WASHINGTON PARK, IL 62204-2135
(618) 482-7922
(618) 215-4048
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1336258540
NPI
IL
Enumeration date
02/22/2016
Last updated
05/24/2016
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