1063544401 NPI number — STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT

Table of content: (NPI 1063544401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063544401 NPI number — STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STARVED ROCK REGIONAL CENTER FOR THERAPY & CHILD DEVELOPMENT
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:
EASTER SEALS OF LASALLE & BUREAU COUNTIES
Provider Other Organization Name Type Code:
4
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:
1063544401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 ADAMS STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OTTAWA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61354-4304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-434-0857
Provider Business Mailing Address Fax Number:
815-434-2260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 ADAMS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTTAWA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61354-4304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-434-0857
Provider Business Practice Location Address Fax Number:
815-434-2260
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
SUE
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
815-434-0857

Provider Taxonomy Codes

  • Taxonomy code: 2081P0010X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X , 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)

  • Identifier: 5015093 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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