Healthcare Provider Details

I. General information

NPI: 1104156439
Provider Name (Legal Business Name): CATHOLIC SOCIAL SERVICES CARBONDALE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2010
Last Update Date: 01/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 S UNIVERSITY AVE
CARBONDALE IL
62901-2925
US

IV. Provider business mailing address

214 S UNIVERSITY AVE
CARBONDALE IL
62901-2925
US

V. Phone/Fax

Practice location:
  • Phone: 618-351-0743
  • Fax: 618-351-0945
Mailing address:
  • Phone: 618-351-0743
  • Fax: 618-351-0945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number003967-11
License Number StateIL

VIII. Authorized Official

Name: MR. GARY B SCHMITT
Title or Position: FINANCE DIRECTOR
Credential: MBA
Phone: 618-688-1127