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1820 Delmar Ave Granite City IL 62040-4507 | |
| (618) 877-4489 | |
| (618) 877-4487 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 1820 Delmar Ave, Granite City, Illinois |
| Authorized Official Name and Position | Larry Mcculley (CHIEF EXECUTIVE OFFICER) |
| Authorized Official Contact | 6183320649 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
8080 State St East Saint Louis IL 62203-1808 Ph: (618) 397-3303 | 1820 Delmar Ave Granite City IL 62040-4507 Ph: (618) 877-4489 |
| NPI Number | 1619150174 |
|---|---|
| Provider Enumeration Date | 12/07/2007 |
| Last Update Date | 04/12/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1619150174 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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