Provider Demographics
NPI:1326376591
Name:ILLINOIS MENTOR
Entity Type:Organization
Organization Name:ILLINOIS MENTOR
Other - Org Name:O'FALLON SITE 014010
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIVIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGWA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:708-679-9137
Mailing Address - Street 1:791 WALL ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1959
Mailing Address - Country:US
Mailing Address - Phone:618-628-9424
Mailing Address - Fax:618-628-9426
Practice Address - Street 1:791 WALL ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:618-628-9424
Practice Address - Fax:618-628-9426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS MENTOR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251B00000XAgenciesCase Management
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities