Provider Demographics
NPI:1144003633
Name:CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
Entity type:Organization
Organization Name:CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERCASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-696-9010
Mailing Address - Street 1:1603 TULLAMORE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-9623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1603 TULLAMORE AVE STE A
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-9623
Practice Address - Country:US
Practice Address - Phone:309-808-6407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL ILLINOIS PREVENTIVE SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty