Provider Demographics
NPI:1871709865
Name:ELGIN WELL CHILD CONFERENCE
Entity type:Organization
Organization Name:ELGIN WELL CHILD CONFERENCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RD,LD
Authorized Official - Phone:847-741-7340
Mailing Address - Street 1:620 WING ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-2800
Mailing Address - Country:US
Mailing Address - Phone:847-741-7370
Mailing Address - Fax:847-741-2413
Practice Address - Street 1:620 WING ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2800
Practice Address - Country:US
Practice Address - Phone:847-741-7370
Practice Address - Fax:847-741-2413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL237378349001Medicaid