Healthcare Provider Details

I. General information

NPI: 1336617869
Provider Name (Legal Business Name): IROQUOIS MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W DIVISION ST
MANTENO IL
60950-1065
US

IV. Provider business mailing address

PO BOX 322
WATSEKA IL
60970-0322
US

V. Phone/Fax

Practice location:
  • Phone: 815-432-5241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: KIM FEAR
Title or Position: HR & FINANCE
Credential:
Phone: 815-432-5241