Provider Demographics
NPI:1093307266
Name:RENEST RECOVERY SUPPORT SERVICES OF ILLINOIS
Entity Type:Organization
Organization Name:RENEST RECOVERY SUPPORT SERVICES OF ILLINOIS
Other - Org Name:RENEST RECOVERY SUPPORT SERVICE ROCKFORD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL, HUMAN RESOURCE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:APSS
Authorized Official - Phone:270-839-6743
Mailing Address - Street 1:910 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2162
Mailing Address - Country:US
Mailing Address - Phone:270-839-6743
Mailing Address - Fax:
Practice Address - Street 1:910 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2162
Practice Address - Country:US
Practice Address - Phone:270-839-6743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health