| Organization Name: | SOUTHERN ILLINOIS REGIONAL WELLNESS CENTER |
| NPI Number: | 1336258540 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARK R FREELAND (EXECUTIVE DIRECTOR) |
| Mailing Address: | 100 N 8th St Suite 232 East Saint Louis |
| State: | IL US |
| Postal Code: | 622012989 |
| Phone Number: | 6188743120 |
| Fax Number: | 6182748927 |
| NPI Enumeration Date: | 08/30/2006 |
| NPI Last Update Date: | 12/06/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |