Provider Demographics
NPI:1568177210
Name:OUR CHILDREN'S HOMESTEAD
Entity Type:Organization
Organization Name:OUR CHILDREN'S HOMESTEAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CLINICAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-369-0004
Mailing Address - Street 1:280 SHUMAN BLVD STE 270
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-3187
Mailing Address - Country:US
Mailing Address - Phone:630-369-0004
Mailing Address - Fax:
Practice Address - Street 1:1401 N 2ND ST STE 2
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3044
Practice Address - Country:US
Practice Address - Phone:815-316-7626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR CHILDREN'S HOMESTEAD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)