Organization
RENEST OF ILLINOIS SUPR
Active
Other names
reNEST
Organization subpart
No
Provider details
NPI number
Authorized official
THERESA WADDELL CADC, MA (ADMINISTRATIVE OFFICE)
(844) 473-6378
Entity
Organization
Contact information
Practice address
910 2ND AVE, ROCKFORD, IL 61104-2162
(844) 473-6378
(270) 246-9950
Mailing address
910 2ND AVE, ROCKFORD, IL 61104-2162
(270) 839-6743
(270) 246-9950
Taxonomy
Speciality
Code
Description
License number
State
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
276400000X
Substance Use Disorder Rehabilitation Hospital Unit
—
—
324500000X
Substance Abuse Rehabilitation Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
A-00229-001-A
—
IL
Enumeration date
07/18/2022
Last updated
03/14/2025
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