Provider Demographics
NPI:1306349576
Name:CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:F
Authorized Official - Last Name:OVERCASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-696-9010
Mailing Address - Street 1:400 CIMMERON DR
Mailing Address - Street 2:
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-7505
Mailing Address - Country:US
Mailing Address - Phone:309-696-9010
Mailing Address - Fax:
Practice Address - Street 1:2426 W CORNERSTONE CT STE 100
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2400
Practice Address - Country:US
Practice Address - Phone:309-966-3137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty