Basic Information
| Provider Information | |||||||||
| NPI: | 1114223245 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROADSTEP ACADEMY-ILLINOIS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2025 WINCHESTER DR | ||||||||
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| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610322932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2011 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | KEDRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 9197090197 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHOENIX CARE SYSTEMS, INC. | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | IL | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
No ID Information.