Provider Demographics
NPI:1801363551
Name:KEMMERER VILLAGE INC.
Entity Type:Organization
Organization Name:KEMMERER VILLAGE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-226-2116
Mailing Address - Street 1:941 N. 2500 EAST ROAD
Mailing Address - Street 2:
Mailing Address - City:ASSUMPTION
Mailing Address - State:IL
Mailing Address - Zip Code:62510
Mailing Address - Country:US
Mailing Address - Phone:217-226-4451
Mailing Address - Fax:217-226-3511
Practice Address - Street 1:941 N. 2500 EAST ROAD
Practice Address - Street 2:
Practice Address - City:ASSUMPTION
Practice Address - State:IL
Practice Address - Zip Code:62510
Practice Address - Country:US
Practice Address - Phone:217-226-4451
Practice Address - Fax:217-226-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3B00-IPI-041Medicaid