Provider Demographics
NPI:1770030074
Name:APOSTOLIC CHRISTIAN HOME OF ROANOKE ILLINOIS INC.
Entity Type:Organization
Organization Name:APOSTOLIC CHRISTIAN HOME OF ROANOKE ILLINOIS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:ISAIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-923-2071
Mailing Address - Street 1:PO BOX 530
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IL
Mailing Address - Zip Code:61561-0530
Mailing Address - Country:US
Mailing Address - Phone:309-923-2071
Mailing Address - Fax:309-923-7919
Practice Address - Street 1:1102 W RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:IL
Practice Address - Zip Code:61561-7528
Practice Address - Country:US
Practice Address - Phone:309-923-2071
Practice Address - Fax:309-923-7919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-02
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0021493332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0021493Medicaid