Provider Demographics
NPI:1578858817
Name:JANET WATTLES CENTER
Entity Type:Organization
Organization Name:JANET WATTLES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-968-9300
Mailing Address - Street 1:526 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1214
Mailing Address - Country:US
Mailing Address - Phone:815-968-9300
Mailing Address - Fax:815-968-5314
Practice Address - Street 1:1509 BENTON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-4322
Practice Address - Country:US
Practice Address - Phone:815-968-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10120962OtherBCBS
IL016Medicaid
IL982280Medicare UPIN