Healthcare Provider Details

I. General information

NPI: 1023289048
Provider Name (Legal Business Name): DISCOVERY HOUSE RF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 E STATE ST
ROCKFORD IL
61108-2274
US

IV. Provider business mailing address

66 PAVILION AVE
PROVIDENCE RI
02905-1522
US

V. Phone/Fax

Practice location:
  • Phone: 815-484-0900
  • Fax: 815-484-1010
Mailing address:
  • Phone: 401-780-2300
  • Fax: 401-780-2397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberA72600001A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberA72600001A
License Number StateIL

VIII. Authorized Official

Name: PETER F MORRIS
Title or Position: COO
Credential:
Phone: 401-780-2300