Provider Demographics
NPI:1902293657
Name:TWO HARBORS INTEGRATIVE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:TWO HARBORS INTEGRATIVE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-343-0771
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61361-0014
Mailing Address - Country:US
Mailing Address - Phone:815-343-0771
Mailing Address - Fax:888-303-1960
Practice Address - Street 1:2220 MARQUETTE RD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1555
Practice Address - Country:US
Practice Address - Phone:815-343-0771
Practice Address - Fax:888-303-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-21
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.001386261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL470965971001Medicaid