Provider Demographics
NPI:1538540190
Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:TAZWOOD MENTAL HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:MINGUS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:309-477-5525
Mailing Address - Street 1:3248 VANDEVER AVE
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-6257
Mailing Address - Country:US
Mailing Address - Phone:309-347-5522
Mailing Address - Fax:309-347-4264
Practice Address - Street 1:601 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611
Practice Address - Country:US
Practice Address - Phone:309-347-5522
Practice Address - Fax:309-347-4264
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAZWOOD MENTAL HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-09
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL949000Medicaid