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Organization
DHS
Active
Organization
DHS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER WEEDMAN (CNA)
(618) 516-2920
Entity
Organization
Contact information
Practice address
109 W WILSON ST, FAIRFIELD, IL 62837-1816
(618) 516-2920
Mailing address
109 W WILSON ST, FAIRFIELD, IL 62837-1816
(618) 516-2920
Taxonomy
Speciality
Code
Description
License number
State
320700000X
Physical Disabilities Residential Treatment Facility
Primary
376K00000X
IL
Other
Enumeration date
09/30/2016
Last updated
09/30/2016
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