Provider Demographics
NPI:1376525204
Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Entity Type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Other - Org Name:JACK MABLEY 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 1:1120 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-1258
Mailing Address - Country:US
Mailing Address - Phone:815-288-8301
Mailing Address - Fax:815-288-8398
Practice Address - Street 1:1120 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-1258
Practice Address - Country:US
Practice Address - Phone:815-288-8301
Practice Address - Fax:815-288-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL830600315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC43534Medicare UPIN
IL830600Medicare UPIN
ILT38623Medicare UPIN
ILE63807Medicare UPIN