1013147289 NPI number — CENTRAL ILLINOIS AUTISM THERAPEUTIC SERVICES, NFP

Table of content: (NPI 1013147289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013147289 NPI number — CENTRAL ILLINOIS AUTISM THERAPEUTIC SERVICES, NFP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL ILLINOIS AUTISM THERAPEUTIC SERVICES, NFP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CIATS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013147289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 767
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTOON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61938-0767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-258-5790
Provider Business Mailing Address Fax Number:
217-345-0910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26 KICKAPOO VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61920-8086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-258-5790
Provider Business Practice Location Address Fax Number:
217-345-0910
Provider Enumeration Date:
07/21/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SKELLEY
Authorized Official First Name:
VIVIAN
Authorized Official Middle Name:
FAYE
Authorized Official Title or Position:
PROGRAM DIRECTOR/SPECIALIST
Authorized Official Telephone Number:
217-821-1752

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)