Healthcare Provider Details

I. General information

NPI: 1821669839
Provider Name (Legal Business Name): COMMUNITY CONNECTIONS AND SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 FOUR LAKES DR.
BELLEVILLE IL
62220
US

IV. Provider business mailing address

2405 FOUR LAKES DR.
BELLEVILLE IL
62220
US

V. Phone/Fax

Practice location:
  • Phone: 618-980-3117
  • Fax:
Mailing address:
  • Phone: 618-980-3117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS DIEDRE FOOTE C FOOTE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-980-3117