Healthcare Provider Details

I. General information

NPI: 1235323841
Provider Name (Legal Business Name): PARENTS AND FRIENDS OF SLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 CASEYVILLE AVE
SWANSEA IL
62226-4517
US

IV. Provider business mailing address

1450 CASEYVILLE AVE
SWANSEA IL
62226-4517
US

V. Phone/Fax

Practice location:
  • Phone: 618-277-7730
  • Fax: 618-277-5423
Mailing address:
  • Phone: 618-277-7730
  • Fax: 618-277-5423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1725481
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KRYSTAL GRUENENFELDER
Title or Position: ADMINISTRATOR
Credential:
Phone: 618-277-7730