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NPI Code Detail

MEDICARE: JANET WATTLES CENTER

MEDICARE: JANET WATTLES CENTER
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
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1BLUE CROSSOTHER10120962

General Provider Information

NPI Number : 1558327544
Entity Type Code : Organization
Provider Name (Legal Business Name) : JANET WATTLES CENTER
Provider Business Mailing Address
First Line : 526 W STATE ST
Second Line :
City : ROCKFORD
State : IL
Zip : 61101-1214
Country : US
Telephone Number : 815-968-9300
Fax Number : 815-968-5314
Provider Business Practice Location Address
First Line : 526 W STATE ST
Second Line :
City : ROCKFORD
State : IL
Zip : 61101-1214
Country : US
Telephone Number : 815-968-9300
Fax Number : 815-968-5314
Authorized Official
Title or Position : CEO/PRESIDENT
Name : MR. PHIL EATON
Credential :
Telephone Number : 815-968-9300
Provider Enumeration Date : 04/26/2006
Last Update Date : 06/14/2011

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Directions to “JANET WATTLES CENTER ” Practice Location

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