=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811659550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHAMROCK SERVICES GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2021
-----------------------------------------------------
Last Update Date | 10/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13023 N SHILOH DR
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62864-7391
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-244-7701
-----------------------------------------------------
Fax | 618-244-7704
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 814
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62864-0017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-927-0290
-----------------------------------------------------
Fax | 618-244-7704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LALLIA SHANKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-927-0290
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------