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General NPI Number Information
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NPI Number | 1679924450
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Entity Type | Organization
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Legal Business Name | ELM CITY REHABILITATION CENTER, INC.
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Dates
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Enumeration Date | 06/23/2016
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Last Update Date | 06/23/2016
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Provider Practice Location Address
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Address Line | 1314 W WALNUT ST
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City | JACKSONVILLE
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State | IL
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Zip | 62650-1148
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Country | US
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Telephone | 217-245-9504
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Fax | 217-245-2350
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Provider Business Mailing Address
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Address Line | 1314 W WALNUT ST
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City | JACKSONVILLE
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State | IL
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Zip | 62650-1148
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Country | US
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Telephone | 217-245-9504
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Fax | 217-245-2350
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | MR. THOMAS R. FREDERICK
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Credential |
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Telephone | 217-245-9504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 | 201200001S
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License Number State | IL
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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 | 0517
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License Number State | IL
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