Provider Demographics
NPI:1679924450
Name:ELM CITY REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:ELM CITY REHABILITATION CENTER, INC.
Other - Org Name:ELM CITY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-245-9504
Mailing Address - Street 1:1314 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1148
Mailing Address - Country:US
Mailing Address - Phone:217-245-9504
Mailing Address - Fax:217-245-2350
Practice Address - Street 1:1314 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1148
Practice Address - Country:US
Practice Address - Phone:217-245-9504
Practice Address - Fax:217-245-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0517251C00000X
IL201200001S320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities