Healthcare Provider Details

I. General information

NPI: 1497123509
Provider Name (Legal Business Name): ILLINOIS MEDICAID-SUBSTANCE ABUSE GALESBURG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-344-4200
  • Fax: 309-344-4281
Mailing address:
  • Phone: 309-344-4200
  • Fax: 309-344-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA-0118-0005-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. BILL ARTHUR NELSON
Title or Position: CEO
Credential: LCPC
Phone: 309-344-4200