Provider Demographics
NPI:1588892475
Name:DECATUR ATHLETIC CLUB
Entity type:Organization
Organization Name:DECATUR ATHLETIC CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF POST REHABILITATION
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-423-7020
Mailing Address - Street 1:1010 W SOUTH SIDE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-4023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W SOUTH SIDE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-4023
Practice Address - Country:US
Practice Address - Phone:217-423-7020
Practice Address - Fax:217-423-7562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation