TAZWOOD MENTAL HEALTH CENTER, INC. (NPI# 1053633263) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1053633263 |
| Entity Type | Organization |
| Organization Name | TAZWOOD MENTAL HEALTH CENTER, INC. |
| Practice Address |
124-126 S. Chicago Street Lincoln IL 62656 |
| Mailing Address |
3248 Vandever Ave Pekin IL 61554-6257 |
| Practice Telephone | 2177326865 |
| Practice Fax Number | 2177327845 |
| Mailing Telephone | 3093475522 |
| Mailing Fax Number | 3093474264 |
| Enumeration Date | 2010-02-16 |
| Last Update Date | 2018-07-12 |
| Authorized Official Name | DAVE WALTER MINGUS (CEO) |
| Authorized Official Telephone | 3093475579 |
| Authorized Official Credential | LCPC |
| Is Organization Subpart | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| N | 251S00000X | Community/Behavioral Health | Agencies | ||
| Y | 261QR0405X |
Clinic/Center Specialization: Rehabilitation, Substance Use Disorder |
Ambulatory Health Care Facilities |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| IL | MEDICARE | 949000 | 01 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1629444070 | Tazwood Mental Health Center, Inc. | Community/Behavioral Health | 210 W. Walnut Street, Canton, IL 61520-2444 | 2015-08-19 |
| 1134464316 | Tazwood Mental Health Center, Inc. | Community/Behavioral Health | 101 S. Major Street, Eureka, IL 61530 | 2012-11-29 |
| 1013186683 | Tazwood Mental Health Center, Inc. | Community Based Residential Treatment Facility, Mental Illness | 1421 Valle Vista Blvd, Pekin, IL 61554 | 2008-02-27 |
| 1568631133 | Tazwood Mental Health Center, Inc. | Community Based Residential Treatment Facility, Mental Illness | 1425 Valle Vista Blvd, Pekin, IL 61554 | 2008-02-27 |
| 1356466007 | Tazwood Mental Health Center, Inc. | Counselor | 111 W. Washington Street, Suite 230, East Peoria, IL 61611 | 2007-03-20 |
| 1760958797 | Tazwood Mental Health Center, Inc. | Clinic/Center | 124 S Chicago St, Lincoln, IL 62656-2719 | 2018-10-17 |
| 1538540190 | Tazwood Mental Health Center, Inc. | Community/Behavioral Health | 601 Taylor St, East Peoria, IL 61611 | 2015-06-09 |
| 1629247366 | Tazwood Mental Health Center, Inc. | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities | 1423 Valle Vista Blvd, Pekin, IL 61554 | 2008-02-27 |
| 1851417091 | Tazwood Mental Health Center, Inc. | Counselor | 3248 Vandever Ave, Pekin, IL 61554-6257 | 2007-03-21 |
| 1760508907 | Tazwood Mental Health Center, Inc. | Counselor | 111 W. Washington Street, Suite 230, East Peoria, IL 61611 | 2007-03-21 |
| Entity Type | Entity Name | Entity Address |
|---|---|---|
| System for Award Management (SAM) Entities | TAZWOOD MENTAL HEALTH CENTER, INC. | 3248 Vandever Ave, Pekin, IL 61554-6257 |
| Street Address |
124-126 S. CHICAGO STREET |
| City | LINCOLN |
| State | IL |
| Zip Code | 62656 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1437678943 | Carissa Jo O'donoghue | Speech-Language Pathologist | 1000 Railer Way, Lincoln, IL 62656 | 2017-09-15 |
| 1083972012 | Cynthia Dorchinecz | Speech-Language Pathologist | 200 Fifth Street, Lincoln, IL 62656 | 2012-04-27 |
| 1104100114 | Jan E Fehrenbacher | Pharmacist | 603 Woodlawn, Lincoln, IL 62656 | 2011-10-10 |
| 1649428756 | Diane E Ulrich | Dentist | 400 N. Chicago St, Lincoln, IL 62656 | 2008-09-03 |
| 1922202944 | Robert C Miller | Dentist | 217 S Kickapoo St, Lincoln, IL 62656 | 2007-06-13 |
| 1720290638 | Lifetime Dental Care of Illinois, PC | Dentist | 411 Keokuk Street, Lincoln, IL 62656 | 2007-05-04 |
| 1982734539 | Wal-mart Stores, Inc. Dba Wal-mart | Technician/Technologist | 825 Malerich Dr., Lincoln, IL 62656 | 2007-03-06 |
| 1861571663 | David R Hepler II | Chiropractor | 2000 Pulaski Street, Lincoln, IL 62656 | 2006-11-03 |
| 1477561793 | Raymond Todd Nobbe | Optometrist | 1400 Woodlawn Road, Lincoln, IL 62656 | 2006-08-03 |
| 1598710345 | Jak Enterprises Inc | Optometrist | 1477 Woodlawn Rd, Lincoln, IL 62656 | 2006-05-23 |
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| Taxonomy Code | 261QR0405X |
| Grouping | Ambulatory Health Care Facilities |
| Classification | Clinic/Center |
| Specialization | Rehabilitation, Substance Use Disorder |
| Definition to come... |
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| 1922634021 | Lutheran Social Services of Illinois | Clinic/Center | 400 N Cherry St, Morrison, IL 61270-2605 | 2020-03-20 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.