=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194721969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY RETIREMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2005
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 423 S EBERHARDT DR
-----------------------------------------------------
City | ARTHUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61911-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-543-2103
-----------------------------------------------------
Fax | 217-543-2278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 S EBERHARDT DR
-----------------------------------------------------
City | ARTHUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61911-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-543-2103
-----------------------------------------------------
Fax | 217-543-2278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MGR
-----------------------------------------------------
Name | SAMANTHA HENSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-543-4548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0005462
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------