Healthcare Provider Details

I. General information

NPI: 1942473327
Provider Name (Legal Business Name): PATTERSON HOUSE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E JEFFERSON ST
SULLIVAN IL
61951-2029
US

IV. Provider business mailing address

PO BOX 25527
DECATUR IL
62525-5527
US

V. Phone/Fax

Practice location:
  • Phone: 217-728-4357
  • Fax: 217-728-9017
Mailing address:
  • Phone: 217-422-6510
  • Fax: 217-422-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0037341
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number0037341
License Number StateIL

VIII. Authorized Official

Name: MS. VERONIKA WILSON
Title or Position: RSD
Credential: QMRP
Phone: 217-728-4357