Provider Demographics
NPI:1851346316
Name:MULLIN MEMORIAL RURAL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:MULLIN MEMORIAL RURAL HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DESALLE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:815-445-2213
Mailing Address - Street 1:320 SOUTH SECOND STREET
Mailing Address - Street 2:P.O. BOX 375
Mailing Address - City:MANLIUS
Mailing Address - State:IL
Mailing Address - Zip Code:61338
Mailing Address - Country:US
Mailing Address - Phone:815-445-2273
Mailing Address - Fax:815-445-2213
Practice Address - Street 1:320 SOUTH SECOND STREET
Practice Address - Street 2:
Practice Address - City:MANLIUS
Practice Address - State:IL
Practice Address - Zip Code:61338
Practice Address - Country:US
Practice Address - Phone:815-445-2273
Practice Address - Fax:815-445-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL176406892001Medicaid
IL176406892001Medicaid