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10850 Lincoln Trl # 20-1861 Fairview Heights IL 62208-0339 | |
| (314) 718-4503 | |
| (618) 416-2708 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Adult Mental Health |
| Location | 10850 Lincoln Trl # 20-1861, Fairview Heights, Illinois |
| Authorized Official Name and Position | Tyrone D Ford (OWNER/MANAGING MEMBER) |
| Authorized Official Contact | 3147184503 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
10850 Lincoln Trl # 20-1861 Fairview Heights IL 62208-0339 Ph: (314) 718-4503 | 10850 Lincoln Trl # 20-1861 Fairview Heights IL 62208-0339 Ph: (314) 718-4503 |
| NPI Number | 1568133189 |
|---|---|
| Provider Enumeration Date | 09/23/2021 |
| Last Update Date | 12/09/2024 |
| Certification Date | 12/09/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1568133189 | NPI | - | NPPES |
| 2016002322 | Other | MO | MO DEPT . OF PROFESSIONAL REGISTRATION |
| 149.018180 | Other | IL | IL DEPT. OF FINANCIAL AND PROFESSIONAL REGULATION |
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