Provider Demographics
NPI:1376979195
Name:EASTER SEALS-UCP
Entity Type:Organization
Organization Name:EASTER SEALS-UCP
Other - Org Name:CFC #14
Other - Org Type:Other Name
Authorized Official - Title/Position:EX VP
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-686-1177
Mailing Address - Street 1:3000 W ROHMANN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-4842
Mailing Address - Country:US
Mailing Address - Phone:309-672-6360
Mailing Address - Fax:309-681-0190
Practice Address - Street 1:3000 W ROHMANN AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-4842
Practice Address - Country:US
Practice Address - Phone:309-672-6360
Practice Address - Fax:309-681-0190
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTER SEALS-UCP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management