Healthcare Provider Details

I. General information

NPI: 1598935504
Provider Name (Legal Business Name): CARROLL & JO DAVIES & STEPHENSON ROE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N RUSH ST
STOCKTON IL
61085-1004
US

IV. Provider business mailing address

500 N. RUSH ST.
STOCKTON IL
61085-1004
US

V. Phone/Fax

Practice location:
  • Phone: 815-947-3810
  • Fax: 815-947-2717
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MARIE STIEFEL
Title or Position: REGIONAL SUPERINTENDENT
Credential:
Phone: 815-947-3810