Healthcare Provider Details

I. General information

NPI: 1457033763
Provider Name (Legal Business Name): RAINBOW CAFE LGBTQ CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N ILLINOIS AVE
CARBONDALE IL
62901-1450
US

IV. Provider business mailing address

118 N ILLINOIS AVE
CARBONDALE IL
62901-1450
US

V. Phone/Fax

Practice location:
  • Phone: 618-525-9922
  • Fax:
Mailing address:
  • Phone: 618-525-9922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER R SOCORRO
Title or Position: CLINICAL DIRECTOR
Credential:
Phone: 618-525-9922