Organization
COMMUNITY RESOURCE CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DENISE DAUM (EXECUTIVE DIRECTOR)
(618) 533-1391
Entity
Organization
Contact information
Practice address
423 W MAIN, VANDALIA, IL 62471
(618) 283-4229
(618) 533-0012
Mailing address
101 S LOCUST ST, CENTRALIA, IL 62801-3506
(618) 533-1391
(618) 533-0012
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
320800000X
Mental Illness Community Based Residential Treatment Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04035
—
IL
01
—
6115207
BLUE CROSS
IL
Enumeration date
02/15/2008
Last updated
02/15/2008
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