=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467647883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS CENTER FOR REHABILITATION AND EDUCATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2007
-----------------------------------------------------
Last Update Date | 09/10/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 W ROOSEVELT RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60608-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-433-3110
-----------------------------------------------------
Fax | 312-433-3180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 W LAWRENCE AVE
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62704-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-524-4089
-----------------------------------------------------
Fax | 217-524-2352
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | MRS. THERESE MANDERINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-433-3121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------