MEDICARE: COMMUNITY LIVING OPTIONS INC

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	38828	IL

General Provider Information

NPI Number	:	1871765222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY LIVING OPTIONS INC

Provider Business Mailing Address
First Line	:	285 SOUTH FARNHAM STREET
Second Line	:
City	:	GALESBURG
State	:	IL
Zip	:	61401-5323
Country	:	US
Telephone Number	:	309-343-1550
Fax Number	:	309-343-6318

Provider Business Practice Location Address
First Line	:	826 W LAFAYETTE
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-1835
Country	:	US
Telephone Number	:	217-245-8200
Fax Number	:	217-245-5255

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	MR. RONALD J WILSON
Credential	:
Telephone Number	:	309-343-1550

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	04/20/2008

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