Provider Demographics
NPI:1174724280
Name:SOUTH SIDE OFFICE OF CONCERN
Entity type:Organization
Organization Name:SOUTH SIDE OFFICE OF CONCERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KAHL
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:309-674-7310
Mailing Address - Street 1:301 NE JEFFERSON STREET
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1212
Mailing Address - Country:US
Mailing Address - Phone:309-674-7310
Mailing Address - Fax:309-674-9652
Practice Address - Street 1:1316 SW ADAMS ST
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1702
Practice Address - Country:US
Practice Address - Phone:309-674-7310
Practice Address - Fax:309-674-9652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04125251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management