Provider Demographics
NPI:1124130208
Name:BELCREST SERVICES, LTD
Entity type:Organization
Organization Name:BELCREST SERVICES, LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-685-0100
Mailing Address - Street 1:1120 E WAR MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-7757
Mailing Address - Country:US
Mailing Address - Phone:309-685-0100
Mailing Address - Fax:309-685-0172
Practice Address - Street 1:2535 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-1863
Practice Address - Country:US
Practice Address - Phone:309-694-6464
Practice Address - Fax:309-694-6032
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BELCREST SERVICES, LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL766340Medicare ID - Type UnspecifiedMEDICARE ID NUMBER