Provider Demographics
NPI:1639298706
Name:RICCA
Entity Type:Organization
Organization Name:RICCA
Other - Org Name:ROCK ISLAND COUNTY COUNCIL ON ADDICTIONS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ENGHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:CADC, CAMS II
Authorized Official - Phone:309-792-0292
Mailing Address - Street 1:1607 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-9662
Mailing Address - Country:US
Mailing Address - Phone:309-792-0292
Mailing Address - Fax:309-792-1121
Practice Address - Street 1:1607 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-9662
Practice Address - Country:US
Practice Address - Phone:309-792-0292
Practice Address - Fax:309-792-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251V00000X
ILA-0625-0004-A261QR0405X
IL261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251V00000XAgenciesVoluntary or Charitable