Healthcare Provider Details

I. General information

NPI: 1750619185
Provider Name (Legal Business Name): HUMAN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2009
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W NEW LEAF LN
PEORIA IL
61615-3311
US

IV. Provider business mailing address

600 FAYETTE ST PO BOX 1346
PEORIA IL
61603-3610
US

V. Phone/Fax

Practice location:
  • Phone: 309-671-8005
  • Fax:
Mailing address:
  • Phone: 309-671-8005
  • Fax: 309-671-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA-0324-0009-A
License Number StateIL

VIII. Authorized Official

Name: MR. MICHAEL KENNEDY
Title or Position: PRESIDENT/CEO
Credential:
Phone: 309-671-8005