Healthcare Provider Details

I. General information

NPI: 1679924450
Provider Name (Legal Business Name): ELM CITY REHABILITATION CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 W WALNUT ST
JACKSONVILLE IL
62650-1148
US

IV. Provider business mailing address

1314 W WALNUT ST
JACKSONVILLE IL
62650-1148
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-9504
  • Fax: 217-245-2350
Mailing address:
  • Phone: 217-245-9504
  • Fax: 217-245-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number0517
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number201200001S
License Number StateIL

VIII. Authorized Official

Name: MR. THOMAS R. FREDERICK
Title or Position: PRESIDENT/CEO
Credential:
Phone: 217-245-9504