Healthcare Provider Details

I. General information

NPI: 1144549494
Provider Name (Legal Business Name): HUMAN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 N ROCHELLE LN
PEORIA IL
61604-1035
US

IV. Provider business mailing address

PO BOX 1346
PEORIA IL
61654-1346
US

V. Phone/Fax

Practice location:
  • Phone: 309-222-2185
  • Fax: 309-282-1089
Mailing address:
  • Phone: 309-671-8005
  • Fax: 309-671-8021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberA-0324-0007A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberPS0144648
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberA0324-0007-A
License Number StateIL

VIII. Authorized Official

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