Healthcare Provider Details

I. General information

NPI: 1114140373
Provider Name (Legal Business Name): COMMUNITY RESIDENTIAL CENTERS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 S CHERRY STREET
GALESBURG IL
61401
US

IV. Provider business mailing address

239 S CHERRY STREET
GALESBURG IL
61401
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-4101
  • Fax: 309-343-4106
Mailing address:
  • Phone: 309-343-4101
  • Fax: 309-343-4106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number003406
License Number StateIL

VIII. Authorized Official

Name: MR. BOBBY D DILLARD
Title or Position: ADMINISTRATOR
Credential: MS LNHA
Phone: 309-343-4101