Provider Demographics
NPI:1932633427
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:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:390-685-1047
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:309-685-1047
Mailing Address - Fax:390-687-7299
Practice Address - Street 1:404 NE MADISON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3720
Practice Address - Country:US
Practice Address - Phone:309-685-1047
Practice Address - Fax:309-687-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0405X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05-IPI-130Medicaid
ILA-6162-0002-AMedicaid