Healthcare Provider Details

I. General information

NPI: 1316110539
Provider Name (Legal Business Name): PIONEER CONCEPTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 EAST 207TH STREET
LYNWOOD IL
60411-1536
US

IV. Provider business mailing address

285 SOUTH FARNHAM STREET
GALESBURG IL
61401-5323
US

V. Phone/Fax

Practice location:
  • Phone: 708-758-3988
  • Fax: 708-758-1821
Mailing address:
  • Phone: 309-343-1550
  • Fax: 309-343-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number43273
License Number StateIL

VIII. Authorized Official

Name: MR. RONALD J WILSON
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 309-343-1550