=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508231879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R&J ENTERPRISES COUNTRY LIVING, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2015
-----------------------------------------------------
Last Update Date | 12/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 EAST AVE
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62906-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-833-7418
-----------------------------------------------------
Fax | 618-833-5400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 221 EAST AVE
-----------------------------------------------------
City | ANNA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62906-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-833-7418
-----------------------------------------------------
Fax | 618-833-5400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACTING DIRECTOR
-----------------------------------------------------
Name | KIMBERLY CATES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-833-7418
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 199400203S
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------