Provider Demographics
NPI:1407026511
Name:ARROWHEAD RANCH
Entity Type:Organization
Organization Name:ARROWHEAD RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF STATE PROGRAMS
Authorized Official - Prefix:DR
Authorized Official - First Name:CHELEASE
Authorized Official - Middle Name:MACHAY
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:ED D
Authorized Official - Phone:309-799-7044
Mailing Address - Street 1:12200 104TH ST
Mailing Address - Street 2:P.O. BOX 370
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9712
Mailing Address - Country:US
Mailing Address - Phone:309-799-7044
Mailing Address - Fax:
Practice Address - Street 1:12200 104TH ST
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9712
Practice Address - Country:US
Practice Address - Phone:309-799-7044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========662Medicaid