=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245781079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHESTNUT HEALTH SYSTEMS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2016
-----------------------------------------------------
Last Update Date | 03/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 MARTIN LUTHER KING DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-827-6026
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1003 MARTIN LUTHER KING DR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61701-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGED CARE SUPERVIOSR
-----------------------------------------------------
Name | MEGAN MARIE TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-924-3786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | A-0126-0010-A
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------