# PIASA MANOR

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1346369642
- **Authorized official:** MRS. CAROL ANN DODD (QMRP)
- **Authorized official phone:** (618) 466-9242

## Contact information

- **Practice address:** 110 N ALBY CT, GODFREY, IL 62035-1963
- **Practice address phone:** (618) 466-9242
- **Practice address fax:** (618) 466-9517
- **Mailing address:** 110 N ALBY CT, GODFREY, IL 62035-1963
- **Mailing address phone:** (618) 466-9242
- **Mailing address fax:** (618) 466-9517

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | 0038422 | IL | Yes |

## Other

- **Enumeration date:** 03/28/2007
- **Last updated:** 08/04/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 371272004 | — | IL |