=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518045442
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY LINK, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 12/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1665 N 4TH ST
-----------------------------------------------------
City | BREESE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62230-1791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-526-8800
-----------------------------------------------------
Fax | 618-526-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1665 N 4TH ST
-----------------------------------------------------
City | BREESE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62230-1791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-526-8800
-----------------------------------------------------
Fax | 618-526-2021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JOHN A HUELSKAMP
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-526-3905
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------