Provider Demographics
NPI:1609223668
Name:EASTER SEALS JOLIET REGION
Entity Type:Organization
Organization Name:EASTER SEALS JOLIET REGION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-927-5451
Mailing Address - Street 1:212 BARNEY DR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5271
Mailing Address - Country:US
Mailing Address - Phone:815-725-2194
Mailing Address - Fax:815-725-5150
Practice Address - Street 1:212 BARNEY DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5271
Practice Address - Country:US
Practice Address - Phone:815-725-2194
Practice Address - Fax:815-725-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 253Z00000X
IL199100088C261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities