=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518411594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRANSITIONS OF WESTERN ILLINOIS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2016
-----------------------------------------------------
Last Update Date | 08/08/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 631 N 48TH ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62305-7918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-224-2194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4409 MAINE ST
-----------------------------------------------------
City | QUINCY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62305-5849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIR OF BUSINESS SERVICES
-----------------------------------------------------
Name | MRS. ANGIE DEAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-223-0423
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------