Healthcare Provider Details

I. General information

NPI: 1114117231
Provider Name (Legal Business Name): STREATOR UNLIMITED INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N STERLING ST
STREATOR IL
61364-2369
US

IV. Provider business mailing address

PO BOX 706 305 N STERLING ST
STREATOR IL
61364-2369
US

V. Phone/Fax

Practice location:
  • Phone: 815-673-5574
  • Fax: 815-673-1714
Mailing address:
  • Phone: 815-673-5574
  • Fax: 815-673-1714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0024265
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number916062
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number002
License Number StateIL

VIII. Authorized Official

Name: MR. JEFFREY MARK DEAN
Title or Position: EXECUTIVE DIRECTOR
Credential: LNHA
Phone: 815-673-5574