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General NPI Number Information
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NPI Number | 1619118304
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Entity Type | Organization
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Legal Business Name | MARTIN LUTHER KING JR. COMMUNITY SERVICE AREA PROJECT
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Dates
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Enumeration Date | 03/10/2009
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Last Update Date | 03/10/2009
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Provider Practice Location Address
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Address Line | 555 N COURT ST STE 204
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City | ROCKFORD
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State | IL
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Zip | 61103-6898
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Country | US
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Telephone | 815-233-9915
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Fax | 815-962-2180
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Provider Business Mailing Address
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Address Line | 555 N COURT ST STE 204
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City | ROCKFORD
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State | IL
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Zip | 61103-6898
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Country | US
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Telephone | 815-233-9915
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Fax | 815-962-2180
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. CHARLES W COLLINS II
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Credential | REV.
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Telephone | 815-233-9915
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 08002
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License Number State | IL
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