Organization
SENIOR ADULT SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HENRY LONG (EXECUTIVE DIRECTOR)
(618) 457-4151
Entity
Organization
Contact information
Practice address
409 N SPRINGER ST, CARBONDALE, IL 62901-1429
(618) 457-4151
Mailing address
409 N SPRINGER ST, CARBONDALE, IL 62901-1429
(618) 457-4151
Taxonomy
Speciality
Code
Description
License number
State
261QA0600X
Adult Day Care Clinic/Center
Primary
—
—
343900000X
Non-emergency Medical Transport (VAN)
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
8694018
—
IL
Enumeration date
01/24/2018
Last updated
01/24/2018
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