Healthcare Provider Details

I. General information

NPI: 1578940557
Provider Name (Legal Business Name): HUMAN SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 12/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 NE JEFFERSON AVE
PEORIA IL
61603-3802
US

IV. Provider business mailing address

PO BOX 1346
PEORIA IL
61654-1346
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA-0324-0005-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number003240005
License Number StateIL

VIII. Authorized Official

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