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General NPI Number Information
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NPI Number | 1477919546
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Entity Type | Organization
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Legal Business Name | DISABILITY SERVICES OF ILLINOIS NFP
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Dates
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Enumeration Date | 01/05/2016
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Last Update Date | 01/05/2016
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Provider Practice Location Address
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Address Line | 286 E 16TH ST
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City | CHICAGO HEIGHTS
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State | IL
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Zip | 60411-3730
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Country | US
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Telephone | 708-753-1670
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Fax | 708-753-1679
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Provider Business Mailing Address
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Address Line | PO BOX 351
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City | MATTESON
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State | IL
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Zip | 60443-0351
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Country | US
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Telephone | 708-753-1670
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Fax | 708-753-1679
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. REUBEN F GOODWIN SR.
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Credential |
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Telephone | 708-753-1670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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