Provider Demographics
NPI:1306107578
Name:DECATUR 2012 LLC
Entity type:Organization
Organization Name:DECATUR 2012 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING PAYER RELATIONS MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 E ALGONQUIN RD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4144
Mailing Address - Country:US
Mailing Address - Phone:888-988-8406
Mailing Address - Fax:847-496-7603
Practice Address - Street 1:141 E PERSHING RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3213
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-7603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
IL0190269201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty