Healthcare Provider Details

I. General information

NPI: 1699733006
Provider Name (Legal Business Name): CATHOLIC CHILDRENS HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 STATE ST
ALTON IL
62002
US

IV. Provider business mailing address

1400 STATE ST
ALTON IL
62002
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-3594
  • Fax: 618-465-4023
Mailing address:
  • Phone: 618-465-3594
  • Fax: 618-465-4023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number00397410
License Number StateIL

VIII. Authorized Official

Name: MR. STEVEN E ROACH
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 217-523-9201