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General NPI Number Information
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NPI Number | 1427236900
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Entity Type | Organization
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Legal Business Name | CARDINAL HOUSE INC
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Dates
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Enumeration Date | 02/06/2008
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Last Update Date | 02/06/2008
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Provider Practice Location Address
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Address Line | 200 DOUGLAS STREET
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City | ANNA
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State | IL
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Zip | 62906
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Country | US
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Telephone | 618-833-7756
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Fax | 618-833-7756
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Provider Business Mailing Address
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Address Line | PO BOX 622
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City | ANNA
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State | IL
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Zip | 62906-0622
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Country | US
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Telephone | 618-833-7756
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Fax | 618-833-7806
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Authorized Official
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Title or Position | EX DIR SE
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Name | MR. GREGORY MICHAEL BLAKELY
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Credential | PT QMRP
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Telephone | 618-833-7756
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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 | 965010
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License Number State | IL
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