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108 Sw Madison Ave Peoria IL 61602-1107 | |
| (309) 673-3769 | |
| (309) 673-4076 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 108 Sw Madison Ave, Peoria, Illinois |
| Authorized Official Name and Position | Roy Fesmire (VICE PRESIDENT AND CFO) |
| Authorized Official Contact | 3127870208 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
700 S Clinton St Chicago IL 60607-4350 Ph: (312) 787-0207 | 108 Sw Madison Ave Peoria IL 61602-1107 Ph: (309) 673-3769 |
| NPI Number | 1902260276 |
|---|---|
| Provider Enumeration Date | 04/12/2016 |
| Last Update Date | 11/30/2016 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902260276 | NPI | - | NPPES |
| 13001 | Medicaid | IL |
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