1184744625 NPI number — INDEPENDENCE HEALTH & THERAPY

Table of content: (NPI 1184744625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184744625 NPI number — INDEPENDENCE HEALTH & THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENCE HEALTH & THERAPY
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:
ADULT & CHILD REHABILITATION CENTER FOR MCHENRY COUNTY ILLINOIS
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:
1184744625
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2028 N. SEMINARY AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60098
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-338-3590
Provider Business Mailing Address Fax Number:
815-337-4406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 WASHINGTON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-338-1707
Provider Business Practice Location Address Fax Number:
815-338-1786
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LARSON
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
815-333-8657

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X , with the licence number: 1747736 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X , with the licence number: 1747736 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 362264411001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05615103 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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