MEDICARE: CENTRAL ILLINOIS FRIENDS OF PWA, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	251K00000X	Public Health or Welfare Agency
3	251V00000X	Voluntary or Charitable Agency
4	251S00000X	Community/Behavioral Health Agency
5	363LC1500X	Community Health Nurse Practitioner
6	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1447866900
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL ILLINOIS FRIENDS OF PWA, INC.

Provider Business Mailing Address
First Line	:	PO BOX 5022
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61601-5022
Country	:	US
Telephone Number	:	309-671-2144
Fax Number	:	309-671-5108

Provider Business Practice Location Address
First Line	:	2112 E WAR MEMORIAL DR
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-8002
Country	:	US
Telephone Number	:	309-431-5880
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DERIC KIMLER
Credential	:
Telephone Number	:	309-671-2144

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	01/23/2026

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