Provider Demographics
NPI:1093961484
Name:CHILDRENS' HOME ASSOCIATION OF ILLINOIS
Entity Type:Organization
Organization Name:CHILDRENS' HOME ASSOCIATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:309-687-7255
Mailing Address - Street 1:2130 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-2460
Mailing Address - Country:US
Mailing Address - Phone:309-687-7255
Mailing Address - Fax:
Practice Address - Street 1:416 NE SAINT MARK CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3742
Practice Address - Country:US
Practice Address - Phone:309-685-1047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid