Healthcare Provider Details

I. General information

NPI: 1700059805
Provider Name (Legal Business Name): KREIDER SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 N MAIN ST
STOCKTON IL
61085-1121
US

IV. Provider business mailing address

PO BOX 366
DIXON IL
61021-0366
US

V. Phone/Fax

Practice location:
  • Phone: 815-947-2235
  • Fax: 815-947-2026
Mailing address:
  • Phone: 815-288-6691
  • Fax: 815-288-1636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0047936
License Number StateIL

VIII. Authorized Official

Name: MR. JEFFREY J STAUTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 815-288-6691