MEDICARE: BROTHER JAMES COURT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	0020495	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386778462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROTHER JAMES COURT

Provider Business Mailing Address
First Line	:	2508 SAINT JAMES RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-9736
Country	:	US
Telephone Number	:	217-544-4876
Fax Number	:	217-747-5914

Provider Business Practice Location Address
First Line	:	2508 SAINT JAMES RD
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62707-9736
Country	:	US
Telephone Number	:	217-544-4876
Fax Number	:	217-747-5914

Authorized Official
Title or Position	:	ADMINISTATOR
Name	:	MR. RON WAMPLER
Credential	:
Telephone Number	:	217-747-5900

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/22/2020

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