| The Otherside | |
|
1717 Philo Rd Suite 23 Urbana IL 61802-6044 | |
| (217) 607-0098 | |
| (217) 298-0142 |
| Full Name | The Otherside |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 1717 Philo Rd, Urbana, Illinois |
| Authorized Official Name and Position | Leonard Eugene Deforge (OWNER/MANAGER) |
| Authorized Official Contact | 2176070098 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| The Otherside 1717 Philo Rd Suite 23 Urbana IL 61802-6044 Ph: (217) 607-0098 | The Otherside 1717 Philo Rd Suite 23 Urbana IL 61802-6044 Ph: (217) 607-0098 |
| NPI Number | 1740543305 |
|---|---|
| Provider Enumeration Date | 06/19/2012 |
| Last Update Date | 06/20/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740543305 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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