NPIMap

Organization Active NPI

Illinois Mentor

  • Foster Care Agency
  • Peoria, IL
National Provider Identifier
1104154277
Registry record updated Dec 3, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Foster Care AgencyTaxonomy code 253J00000X
Legal business name
ILLINOIS MENTOR
Practice address
4507 N Sterling Ave
Peoria, IL 61615-3824
Phone
(309) 676-6131
Fax
(309) 676-5655
NPI assigned
Nov 30, 2009
Organization subpart
Yes
Parent organization
ILLINOIS MENTORAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 3, 2010

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Viviane Ngwa, MSW
Title
Executive Director
Phone
(708) 679-9137

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Case Management Agency 251B00000X
Foster Care Agency 253J00000X Primary
Intellectual and/or Developmental Disabilities Residential Treatment Facility 320600000X

Addresses

Primary practice location

4507 N Sterling Ave
Peoria, IL 61615-3824

Mailing address

4507 N Sterling Ave
Peoria, IL 61615-3824
Phone (309) 676-6131

Other names 1

  • Peoria Site 014030 Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Illinois Mentor8 organizations share this tax ID, including this one
Part of
Illinois Mentor

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4507 N Sterling Ave
Peoria, IL 61615
Phone (309) 339-5835

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1259539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1291334400000",
    "number": "1104154277",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4507 N STERLING AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616153824",
            "telephone_number": "309-676-6131",
            "fax_number": "309-676-5655"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4507 N STERLING AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616153824",
            "telephone_number": "309-676-6131",
            "fax_number": "309-676-5655"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ILLINOIS MENTOR",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ILLINOIS MENTOR",
        "enumeration_date": "2009-11-30",
        "last_updated": "2010-12-03",
        "status": "A",
        "authorized_official_last_name": "NGWA",
        "authorized_official_first_name": "VIVIANE",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "708-679-9137",
        "authorized_official_credential": "MSW"
    },
    "taxonomies": [
        {
            "code": "251B00000X",
            "taxonomy_group": "",
            "desc": "Case Management",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "253J00000X",
            "taxonomy_group": "",
            "desc": "Foster Care Agency",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peoria Site 014030",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Peoria, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 3, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.