Illinois Mentor

Primary specialty

Foster Care AgencyTaxonomy code 253J00000X

Legal business name

ILLINOIS MENTOR

Doing business as

O'Fallon Site 014010

Practice address

791 Wall St
O Fallon, IL 62269-1959

Phone

(618) 628-9424

Fax

(618) 628-9426

NPI assigned

Nov 30, 2009

Last updated

Nov 30, 2009By the provider in NPPES

Organization subpart

Yes

Parent organization

ILLINOIS MENTORAs reported in NPPES

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

Addresses

Other names 1

• O'Fallon Site 014010 Doing business as

Part of

Illinois Mentor

Locations

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

{
    "created_epoch": "1259539200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1259539200000",
    "number": "1326376591",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "791 WALL ST",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691959",
            "telephone_number": "618-628-9424",
            "fax_number": "618-628-9426"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "791 WALL ST",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691959",
            "telephone_number": "618-628-9424",
            "fax_number": "618-628-9426"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ILLINOIS MENTOR",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ILLINOIS MENTOR",
        "enumeration_date": "2009-11-30",
        "last_updated": "2009-11-30",
        "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": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "253J00000X",
            "taxonomy_group": "",
            "desc": "Foster Care Agency",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "O'Fallon Site 014010",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Providers in O'Fallon, IL by specialty
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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 30, 2009; 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.