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General NPI Number Information
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NPI Number | 1265897201
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN RESIDENTIAL ALTERNATIVES, INC.
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Dates
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Enumeration Date | 12/17/2015
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Last Update Date | 12/17/2015
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Provider Practice Location Address
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Address Line | 125 W CLARK ST
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City | HARRISBURG
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State | IL
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Zip | 62946-2738
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Country | US
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Telephone | 618-272-5007
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Fax | 618-272-3091
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Provider Business Mailing Address
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Address Line | PO BOX 465
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City | HARRISBURG
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State | IL
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Zip | 62946-0465
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Country | US
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Telephone | 618-272-5007
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Fax | 618-272-3091
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Authorized Official
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Title or Position | PRESIDENT OF THE BOARD
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Name | GRANT CAPE
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Credential |
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Telephone | 618-272-5007
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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