Healthcare Provider Details

I. General information

NPI: 1023516044
Provider Name (Legal Business Name): SENIOR ADULT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 01/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 N SPRINGER ST
CARBONDALE IL
62901-1429
US

IV. Provider business mailing address

409 N SPRINGER ST
CARBONDALE IL
62901-1429
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-4151
  • Fax:
Mailing address:
  • Phone: 618-457-4151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: HENRY LONG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 618-457-4151