Healthcare Provider Details

I. General information

NPI: 1487986436
Provider Name (Legal Business Name): KREIDER SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2010
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 WASHINGTON AVE
DIXON IL
61021-1254
US

IV. Provider business mailing address

PO BOX 366
DIXON IL
61021-0366
US

V. Phone/Fax

Practice location:
  • Phone: 815-288-4422
  • Fax:
Mailing address:
  • Phone: 815-288-6691
  • Fax: 815-288-1636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number26385
License Number StateIL

VIII. Authorized Official

Name: MR. JEFFREY J STAUTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 815-288-6691