=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124457825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS MENTOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2013
-----------------------------------------------------
Last Update Date | 11/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 615 N LONGWOOD ST
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61107-4265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 181-528-2615
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 HOLIDAY PLAZA DR SUITE 400
-----------------------------------------------------
City | MATTESON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60443-2241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 170-867-9913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SARA SPENCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 17086799137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------