Healthcare Provider Details

I. General information

NPI: 1013054154
Provider Name (Legal Business Name): KASKASKIA WORKSHOP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 SWAN AVE
CENTRALIA IL
62801
US

IV. Provider business mailing address

PO BOX 1946
CENTRALIA IL
62801-9127
US

V. Phone/Fax

Practice location:
  • Phone: 618-533-4423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: GREG SHAVER
Title or Position: CEO
Credential:
Phone: 618-533-4423