Provider Demographics
NPI:1306926175
Name:QUAD CITIES CITIZENS WITH AUTISM REHABILITATION ENTERPRISE
Entity type:Organization
Organization Name:QUAD CITIES CITIZENS WITH AUTISM REHABILITATION ENTERPRISE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO QC CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-269-0803
Mailing Address - Street 1:1812 7TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201
Mailing Address - Country:US
Mailing Address - Phone:309-786-0336
Mailing Address - Fax:
Practice Address - Street 1:1905 W 40TH ST
Practice Address - Street 2:APT 304
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-4705
Practice Address - Country:US
Practice Address - Phone:309-269-0803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL17053152018035320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities