Provider Demographics
NPI:1154848216
Name:CHILDREN'S HOME ASSOCIATION OF ILLINOIS
Entity Type:Organization
Organization Name:CHILDREN'S HOME ASSOCIATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-687-7241
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:
Mailing Address - Fax:
Practice Address - Street 1:7225 W PLANK RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5252
Practice Address - Country:US
Practice Address - Phone:309-687-7241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-6162-0001-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-130Medicaid
ILA-6162-0001-AMedicaid