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10314 Lincoln Trl Ste 106 Fairview Heights IL 62208-1801 | |
| (618) 875-9355 | |
| (630) 425-8900 |
| Full Name | |
|---|---|
| Speciality | Social Worker - Clinical |
| Location | 10314 Lincoln Trl Ste 106, Fairview Heights, Illinois |
| Authorized Official Name and Position | Chester A Carothers (SOLE MEMBER) |
| Authorized Official Contact | 6188759355 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 6152 East Saint Louis IL 62202-6152 Ph: (618) 875-9355 | 10314 Lincoln Trl Ste 106 Fairview Heights IL 62208-1801 Ph: (618) 875-9355 |
| NPI Number | 1083072524 |
|---|---|
| Provider Enumeration Date | 01/28/2016 |
| Last Update Date | 01/25/2022 |
| Certification Date | 01/25/2022 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1083072524 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 149.017330 (Illinois) | Primary |
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