Healthcare Provider Details

I. General information

NPI: 1346378312
Provider Name (Legal Business Name): TRADE INDUSTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 14 EAST
MC LEANSBORO IL
62859-0070
US

IV. Provider business mailing address

PO BOX 70
MC LEANSBORO IL
62859-0070
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-4321
  • Fax: 618-643-4230
Mailing address:
  • Phone: 618-643-4321
  • Fax: 618-643-4230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0491
License Number StateIL

VIII. Authorized Official

Name: MR. MARK A AUTEN
Title or Position: VICE PRESIDENT
Credential: MBA
Phone: 618-643-4321