Healthcare Provider Details

I. General information

NPI: 1962658120
Provider Name (Legal Business Name): HOME AND ENVIRONMENTS FOR LIVING AND PROGRAMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E 3RD ST
LEBANON IL
62254-1668
US

IV. Provider business mailing address

40 ADLOFF LN STE 5
SPRINGFIELD IL
62703-4496
US

V. Phone/Fax

Practice location:
  • Phone: 618-537-4133
  • Fax: 618-537-4156
Mailing address:
  • Phone: 217-529-9632
  • Fax: 217-529-9635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number0038430
License Number StateIL

VIII. Authorized Official

Name: MS. CATHERINE A BROOKSHIRE
Title or Position: ADMINISTRATOR
Credential:
Phone: 217-529-9632