Healthcare Provider Details

I. General information

NPI: 1831486521
Provider Name (Legal Business Name): JANET WATTLES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2011
Last Update Date: 07/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2014 AUBURN ST
ROCKFORD IL
61103-4479
US

IV. Provider business mailing address

526 W STATE ST
ROCKFORD IL
61101-1214
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax:
Mailing address:
  • Phone: 815-968-9300
  • Fax: 815-968-5314

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 State

VIII. Authorized Official

Name: PHIL EATON
Title or Position: CEO/PRESIDENT
Credential:
Phone: 815-968-9300