Healthcare Provider Details

I. General information

NPI: 1215359492
Provider Name (Legal Business Name): ELIJAH'S JOURNEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 TECUMSEH DR
BOLINGBROOK IL
60490-5564
US

IV. Provider business mailing address

269 TECUMSEH DR
BOLINGBROOK IL
60490-5564
US

V. Phone/Fax

Practice location:
  • Phone: 815-621-6406
  • Fax:
Mailing address:
  • Phone: 815-621-6406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LESLIE LARRY
Title or Position: DIRECTOR
Credential: MBA
Phone: 815-621-6406