Organization
COMMUNITY RESOURCE CENTER INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GEORGIANNE BROUGHTON (EXECUTIVE DIRECTOR)
(618) 533-1391
Entity
Organization
Contact information
Practice address
421 W MAIN ST, VANDALIA, IL 62471-2214
(618) 283-4229
(618) 533-0012
Mailing address
904 E. MARTIN LUTHER KING DRIVE, CENTRALIA, IL 62801-3506
(618) 533-1391
(618) 533-0012
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04035
—
IL
01
—
6115207
BLUE CROSS
IL
01
—
A-00235-0001-A
DHS LICENSE NUMBER
IL
01
—
A-00235-0002-A
DHS LICENSE NUMBER
IL
01
—
A-00235-0003-A
DHS LICENSE NUMBER
IL
01
—
A-00235-0004-A
DHS LICENSE NUMBER
IL
Enumeration date
02/11/2008
Last updated
12/17/2021
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