Provider Demographics
NPI:1154453991
Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Other - Org Name:CHOATE MENTAL HEALTH & DEVELOPMENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FISCAL ADMINISTRATOR, SODC OPERATIO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHLSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-288-8335
Mailing Address - Street 1:1000 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1652
Mailing Address - Country:US
Mailing Address - Phone:618-833-5161
Mailing Address - Fax:
Practice Address - Street 1:1000 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1652
Practice Address - Country:US
Practice Address - Phone:618-833-5161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14G045Medicaid