Provider Demographics
NPI:1821042474
Name:EASTER SEALS CHILDREN'S DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:EASTER SEALS CHILDREN'S DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAWACKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-491-4131
Mailing Address - Street 1:650 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-6921
Mailing Address - Country:US
Mailing Address - Phone:815-965-6745
Mailing Address - Fax:815-965-6021
Practice Address - Street 1:650 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-6921
Practice Address - Country:US
Practice Address - Phone:815-965-6745
Practice Address - Fax:815-965-6021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070002098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid