Provider Demographics
NPI:1851557086
Name:CHILDREN'S HOME ASSOCIATION OF ILLINOIS
Entity Type:Organization
Organization Name:CHILDREN'S HOME ASSOCIATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:309-687-7255
Mailing Address - Street 1:2130 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-2460
Mailing Address - Country:US
Mailing Address - Phone:309-687-7255
Mailing Address - Fax:
Practice Address - Street 1:7225 W PLANK RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5252
Practice Address - Country:US
Practice Address - Phone:309-687-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========015Medicaid