Basic Information
| Provider Information | |||||||||
| NPI: | 1003152976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BETTIS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | DENNIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 W SPRESSER ST | ||||||||
| Address2: | |||||||||
| City: | TAYLORVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625681714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178245210 | ||||||||
| FaxNumber: | 2178245211 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 W SPRESSER ST | ||||||||
| Address2: | |||||||||
| City: | TAYLORVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625681714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2178245210 | ||||||||
| FaxNumber: | 2178245211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2012 | ||||||||
| LastUpdateDate: | 12/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X | 1966 | IL | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.