MEDICARE: COMMUNITY CONNECTIONS AND SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1821669839
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CONNECTIONS AND SERVICES, LLC

Provider Business Mailing Address
First Line	:	2405 FOUR LAKES DR.
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220
Country	:	US
Telephone Number	:	618-980-3117
Fax Number	:

Provider Business Practice Location Address
First Line	:	2405 FOUR LAKES DR.
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220
Country	:	US
Telephone Number	:	618-980-3117
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MISS DIEDRE FOOTE C FOOTE
Credential	:
Telephone Number	:	618-980-3117

Provider Enumeration Date	:	07/09/2021
Last Update Date	:	07/09/2021

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