Healthcare Provider Details

I. General information

NPI: 1073786562
Provider Name (Legal Business Name): PATTERSON HOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 BARNEY AVE
PEKIN IL
61554-6233
US

IV. Provider business mailing address

PO BOX 25527
DECATUR IL
62525-5527
US

V. Phone/Fax

Practice location:
  • Phone: 309-347-6514
  • Fax: 309-347-6146
Mailing address:
  • Phone: 217-422-6510
  • Fax: 217-422-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0039370
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number0039370
License Number StateIL

VIII. Authorized Official

Name: MR. RICH SLOAN
Title or Position: RSD
Credential: QMRP
Phone: 309-347-6514