Healthcare Provider Details

I. General information

NPI: 1568518496
Provider Name (Legal Business Name): FELLOWSHIP HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MAIN ST
ANNA IL
62906-1665
US

IV. Provider business mailing address

800 N MAIN ST P.O. BOX 682
ANNA IL
62906-1665
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-4456
  • Fax: 618-833-2371
Mailing address:
  • Phone: 618-833-4456
  • Fax: 618-833-2371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberA-0626-0002-A
License Number StateIL

VIII. Authorized Official

Name: MS. MICKEY RAE FINCH
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.S.
Phone: 618-833-4456