Healthcare Provider Details

I. General information

NPI: 1043482979
Provider Name (Legal Business Name): COMMUNITY RESIDENTIAL CENTERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 SOUTH CHERRY STREET
GALESBURG IL
61401-4911
US

IV. Provider business mailing address

285 SOUTH FARNHAM STREET
GALESBURG IL
61401-5323
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-4101
  • Fax: 309-343-4118
Mailing address:
  • Phone: 309-343-1550
  • Fax: 309-343-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number34066
License Number StateIL

VIII. Authorized Official

Name: MR. RONALD J WILSON
Title or Position: AUTHORIZED AGENT
Credential:
Phone: 309-343-1550