Healthcare Provider Details

I. General information

NPI: 1033157748
Provider Name (Legal Business Name): CHADDOCK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S 24TH ST
QUINCY IL
62301-4446
US

IV. Provider business mailing address

205 S 24TH ST
QUINCY IL
62301-4446
US

V. Phone/Fax

Practice location:
  • Phone: 217-222-0034
  • Fax: 217-222-3865
Mailing address:
  • Phone: 217-222-0034
  • Fax: 217-222-3865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number308658-03
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number004049-10
License Number StateIL

VIII. Authorized Official

Name: KRISTEN PATTON
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 217-592-0317