Provider Demographics
NPI:1215944152
Name:FAMILY HEALTHCARE CLINIC & REHAB
Entity type:Organization
Organization Name:FAMILY HEALTHCARE CLINIC & REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/AGENT
Authorized Official - Prefix:
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:EBONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-253-8863
Mailing Address - Street 1:701 N COMMERCIAL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946-3335
Mailing Address - Country:US
Mailing Address - Phone:618-253-8863
Mailing Address - Fax:618-253-8864
Practice Address - Street 1:701 N COMMERCIAL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-3335
Practice Address - Country:US
Practice Address - Phone:618-253-8863
Practice Address - Fax:618-253-8864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL148973261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL209908Medicare ID - Type Unspecified