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General NPI Number Information
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NPI Number | 1396100269
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Entity Type | Organization
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Legal Business Name | SKYSTAR RESIDENTIAL SERVICES
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Dates
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Enumeration Date | 12/21/2015
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Last Update Date | 12/21/2015
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Provider Practice Location Address
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Address Line | 406 E DOUGLAS ST
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City | DE SOTO
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State | IL
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Zip | 62924-1516
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Country | US
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Telephone | 618-867-3188
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Fax | 618-867-3098
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Provider Business Mailing Address
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Address Line | 406 EAST DOUGLAS
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City | DESOTO
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State | IL
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Zip | 62924
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Country | US
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Telephone | 618-867-3188
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Fax | 618-867-3098
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Authorized Official
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Title or Position | ED
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Name | MR. RANDALL S DUNCAN
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Credential |
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Telephone | 618-867-3188
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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 | 099600004S
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License Number State | IL
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