Basic Information
| Provider Information | |||||||||
| NPI: | 1265762355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KREIDER SERVICES INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BOYD AVENUE HOME | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 366 | ||||||||
| Address2: | |||||||||
| City: | DIXON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610210366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152886691 | ||||||||
| FaxNumber: | 8152881636 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 S BOYD AVE | ||||||||
| Address2: | |||||||||
| City: | AMBOY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613101506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8158572299 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2010 | ||||||||
| LastUpdateDate: | 07/26/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STAUTER | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8152886691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 40188 | IL | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.