Provider Demographics
NPI:1528482148
Name:SOUTH SIDE OFFICE OF CONCERN
Entity type:Organization
Organization Name:SOUTH SIDE OFFICE OF CONCERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-222-2560
Mailing Address - Street 1:202 NE MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1285
Mailing Address - Country:US
Mailing Address - Phone:309-674-7310
Mailing Address - Fax:309-674-9652
Practice Address - Street 1:202 NE MADISON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1285
Practice Address - Country:US
Practice Address - Phone:309-674-7310
Practice Address - Fax:309-674-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health