Provider Demographics
NPI:1871228494
Name:RENEST OF ILLINOIS SUPR
Entity type:Organization
Organization Name:RENEST OF ILLINOIS SUPR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:CADC, MA
Authorized Official - Phone:844-473-6378
Mailing Address - Street 1:910 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2162
Mailing Address - Country:US
Mailing Address - Phone:270-839-6743
Mailing Address - Fax:270-246-9950
Practice Address - Street 1:910 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2162
Practice Address - Country:US
Practice Address - Phone:844-473-6378
Practice Address - Fax:270-246-9950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-00229-001-AMedicaid