=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366880973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY KITCHEN, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2013
-----------------------------------------------------
Last Update Date | 06/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 KILBURN AVE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61101-6550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-963-1609
-----------------------------------------------------
Fax | 815-963-1627
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 KILBURN AVE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61101-6550
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-963-1609
-----------------------------------------------------
Fax | 815-963-1627
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. CAROL GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-963-1609
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------