Provider Demographics
NPI:1033401815
Name:CHILDRITE DEVELOPMENT
Entity Type:Organization
Organization Name:CHILDRITE DEVELOPMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-652-0146
Mailing Address - Street 1:399 BERLIN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:IL
Mailing Address - Zip Code:62670-4541
Mailing Address - Country:US
Mailing Address - Phone:217-652-0146
Mailing Address - Fax:
Practice Address - Street 1:399 BERLIN RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:IL
Practice Address - Zip Code:62670-4541
Practice Address - Country:US
Practice Address - Phone:217-652-0146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005570332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid