Organization
CHANGES PLACE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACK PHILLIPS CADC (ADMINISTRATOR)
(815) 316-0699
Entity
Organization
Contact information
Practice address
258 N PHELPS AVE, ROCKFORD, IL 61108-2433
(815) 316-0699
(815) 316-0698
Mailing address
258 N PHELPS AVE, ROCKFORD, IL 61108-2433
(815) 316-0699
(815) 316-0698
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
A47410002A
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A47410001A
LICENSED OUTPATIENT SUBSTANCE ABUSE TREATMENT PROVIDER
IL
01
—
A47410002A
LICENSED OUTPATIENT SUBSTANCE ABUSE TREATMENT PROVIDER
IL
Enumeration date
07/10/2008
Last updated
07/10/2008
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