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General NPI Number Information
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NPI Number | 1790143444
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Entity Type | Organization
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Legal Business Name | SOJOURN HOUSE
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Dates
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Enumeration Date | 02/09/2016
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Last Update Date | 02/09/2016
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Provider Practice Location Address
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Address Line | 565 N TURNER AVE
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City | FREEPORT
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State | IL
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Zip | 61032-3252
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Country | US
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Telephone | 815-232-5121
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Fax | 815-233-4591
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Provider Business Mailing Address
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Address Line | 565 N TURNER AVE
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City | FREEPORT
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State | IL
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Zip | 61032-3252
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Country | US
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Telephone | 815-232-5121
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Fax | 815-233-4591
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. DAVE MANSON
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Credential | MS, CADC, MISA 1
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Telephone | 815-232-5121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | A-0595-0001-A
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License Number State | IL
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