Provider Demographics
NPI:1093110066
Name:OTTAWA FRIENDSHIP HOUSE WORK ACTIVITY CENTER, INC
Entity Type:Organization
Organization Name:OTTAWA FRIENDSHIP HOUSE WORK ACTIVITY CENTER, INC
Other - Org Name:GLENWOOD HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MANGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-434-0737
Mailing Address - Street 1:1718 N 2525TH RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-9329
Mailing Address - Country:US
Mailing Address - Phone:815-434-0737
Mailing Address - Fax:815-434-0493
Practice Address - Street 1:600 WEST 12TH STREET
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364
Practice Address - Country:US
Practice Address - Phone:815-673-1182
Practice Address - Fax:815-673-3231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14G282Medicaid