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General NPI Number Information
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NPI Number | 1881857514
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Entity Type | Organization
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Legal Business Name | KCCDD, INC.
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 09/06/2019
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Provider Practice Location Address
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Address Line | 2015 WINDISH DR
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City | GALESBURG
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State | IL
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Zip | 61401-9774
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Country | US
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Telephone | 309-344-2600
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Fax | 309-344-1754
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Provider Business Mailing Address
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Address Line | 2015 WINDISH DR
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City | GALESBURG
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State | IL
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Zip | 61401-9774
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Country | US
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Telephone | 309-344-2600
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Fax | 309-344-1754
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MR. MARK EDWIN RUDOLPH
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Credential |
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Telephone | 309-344-2600
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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 | A000103309
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 261QA0600X
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Taxonomy Name | Adult Day Care Clinic/Center
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License Number |
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License Number State |
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