Healthcare Provider Details

I. General information

NPI: 1932243920
Provider Name (Legal Business Name): WM. W. FOX DEVELOPMENTAL CENTER 3A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W MAIN ST
DWIGHT IL
60420-1322
US

IV. Provider business mailing address

134 W MAIN ST
DWIGHT IL
60420-1322
US

V. Phone/Fax

Practice location:
  • Phone: 815-584-3347
  • Fax:
Mailing address:
  • Phone: 815-584-3347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. GUS PEDRAZA
Title or Position: MEDICAL DIRECTOR
Credential:
Phone: 815-584-3347