Provider Demographics
NPI:1447351028
Name:INSTACLINIC OF ILLINOIS, LLC
Entity type:Organization
Organization Name:INSTACLINIC OF ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOHN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:314-238-1275
Mailing Address - Street 1:10805 SUNSET OFFICE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63127
Mailing Address - Country:US
Mailing Address - Phone:314-238-1275
Mailing Address - Fax:314-238-1250
Practice Address - Street 1:2811 HOMER ADAMS PARKWAY
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:314-238-1275
Practice Address - Fax:314-238-1250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216708OtherNEW PTAN MASS IMMUNIZER PROVIDER NUMBER