Provider Demographics
NPI:1407079635
Name:MILESTONE, INC.
Entity Type:Organization
Organization Name:MILESTONE, INC.
Other - Org Name:MILESTONE-ELMWOOD HEIGHTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:M.
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:WAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-639-2817
Mailing Address - Street 1:4060 MCFARLAND RD
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-4402
Mailing Address - Country:US
Mailing Address - Phone:815-654-6100
Mailing Address - Fax:815-654-6444
Practice Address - Street 1:2662 ELMWOOD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-1573
Practice Address - Country:US
Practice Address - Phone:815-877-7001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0024943320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid