Provider Demographics
NPI:1679639967
Name:ILLINOIS DEPARTMENT OF HUMAN SEVICES
Entity Type:Organization
Organization Name:ILLINOIS DEPARTMENT OF HUMAN SEVICES
Other - Org Name:ANN KILEY DEVELOPMENTAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FISCAL ADMINISTRATOR, SODC OPERATIO
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHLSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-288-8335
Mailing Address - Street 1:3649 WHIRLAWAY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062
Mailing Address - Country:US
Mailing Address - Phone:847-509-1254
Mailing Address - Fax:847-509-1255
Practice Address - Street 1:1401 W DUGDALE RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-249-0600
Practice Address - Fax:847-249-0967
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ILLINOIS DEPARTMENT OF HUMAN SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-29
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067892261QD1600X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities