Healthcare Provider Details

I. General information

NPI: 1629328802
Provider Name (Legal Business Name): CHRISTIAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 WITHERS DR
MOUNT VERNON IL
62864-8273
US

IV. Provider business mailing address

219 WITHERS DR
MOUNT VERNON IL
62864-8273
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-0344
  • Fax: 618-244-1455
Mailing address:
  • Phone: 618-244-0344
  • Fax: 618-244-1455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number003976-12
License Number StateIL

VIII. Authorized Official

Name: BRAD G. BECK
Title or Position: ASSOCIATE EXECUTIVE DIRECTOR
Credential: MPA
Phone: 618-688-1161