=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245368489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY SERVICE OPTIONS FOR ROCK ISLAND MERCER COUNTIES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 MORTON DR SUITE 1
-----------------------------------------------------
City | EAST MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61244-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-278-0020
-----------------------------------------------------
Fax | 309-278-0024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3601 MORTON DR SUITE 1
-----------------------------------------------------
City | EAST MOLINE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61244-1917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-278-0020
-----------------------------------------------------
Fax | 309-278-0024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. DAWN MARIE IMEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-278-0020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------