Provider Demographics
NPI:1225415136
Name:HUMAN SERVICE CENTER
Entity Type:Organization
Organization Name:HUMAN SERVICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-671-8005
Mailing Address - Street 1:PO BOX 1346
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61654-1346
Mailing Address - Country:US
Mailing Address - Phone:309-671-8005
Mailing Address - Fax:309-671-8039
Practice Address - Street 1:3500 W NEW LEAF LANE
Practice Address - Street 2:RETREAT WING
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615
Practice Address - Country:US
Practice Address - Phone:309-671-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-29
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0324-0009-A261QR0405X
IL003240009324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0100324Medicaid