Provider Demographics
NPI:1104361633
Name:STATE OF IL DEPT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:STATE OF IL DEPT OF HUMAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTENBACHER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:815-426-6299
Mailing Address - Street 1:3334 N 12,000 W ROAD
Mailing Address - Street 2:
Mailing Address - City:BONFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60913-7383
Mailing Address - Country:US
Mailing Address - Phone:815-426-6299
Mailing Address - Fax:
Practice Address - Street 1:1617 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6724
Practice Address - Country:US
Practice Address - Phone:815-730-4231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1744428251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health