Provider Demographics
NPI:1447866900
Name:CENTRAL ILLINOIS FRIENDS OF PWA, INC.
Entity type:Organization
Organization Name:CENTRAL ILLINOIS FRIENDS OF PWA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-671-2144
Mailing Address - Street 1:PO BOX 5022
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61601-5022
Mailing Address - Country:US
Mailing Address - Phone:309-671-2144
Mailing Address - Fax:309-671-5108
Practice Address - Street 1:120 NE GLEN OAK AVE STE 201
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4315
Practice Address - Country:US
Practice Address - Phone:309-671-2144
Practice Address - Fax:309-671-5108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center