| Organization Name: | ILLINOIS MEDICAID- SUBSTANCE ABUSE KEWANEE |
| NPI Number: | 1386011161 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BILL A NELSON (CEO) |
| Mailing Address: | 137 E College St Kewanee |
| State: | IL US |
| Postal Code: | 614433703 |
| Phone Number: | 3098524331 |
| Fax Number: | |
| NPI Enumeration Date: | 08/27/2015 |
| NPI Last Update Date: | 08/27/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | A-0118-0003-A |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | IL |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |