1912179045 NPI number — COMMUNITY LIVING OPTIONS INC

Table of content: (NPI 1912179045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912179045 NPI number — COMMUNITY LIVING OPTIONS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY LIVING OPTIONS INC
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:
DOUGLAS TERRACE
Provider Other Organization Name Type Code:
3
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:
1912179045
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 SOUTH FARNHAM STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALESBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61401-5323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-343-1550
Provider Business Mailing Address Fax Number:
309-343-6318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
324 E DOUGLAS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62650-2047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-245-0818
Provider Business Practice Location Address Fax Number:
217-245-0822
Provider Enumeration Date:
03/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
AUTHORIZED AGENT
Authorized Official Telephone Number:
309-343-1550

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  35774 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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