| Substance Abuse Outpatient | |
|
16338 N Il Hwy 37 Mt Vernon IL 62864 | |
| (618) 242-1994 | |
| (618) 242-6392 |
| Full Name | Substance Abuse Outpatient |
|---|---|
| Speciality | Substance Abuse Rehabilitation Facility |
| Location | 16338 N Il Hwy 37, Mt Vernon, Illinois |
| Authorized Official Name and Position | Daniel P Boehmer (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 6182421994 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Substance Abuse Outpatient Po Box 428 Mount Vernon IL 62864-0054 Ph: (618) 242-1994 | Substance Abuse Outpatient 16338 N Il Hwy 37 Mt Vernon IL 62864 Ph: (618) 242-1994 |
| NPI Number | 1649404708 |
|---|---|
| Provider Enumeration Date | 05/05/2009 |
| Last Update Date | 08/17/2018 |
| Medicare PECOS PAC ID | 1153350103 |
|---|---|
| Medicare Enrollment ID | O20050810000128 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1649404708 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | 002250003 (Illinois) | Secondary |
| 324500000X | Substance Abuse Rehabilitation Facility | 002250003 (Illinois) | Primary |
| Provider Name | Angela D Betters |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1295442325 PECOS PAC ID: 8820451263 Enrollment ID: I20230831003369 |
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