Basic Information
| Provider Information | |||||||||
| NPI: | 1245408491 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY RESOURCE CENTER INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 904 E. MARTIN LUTHER KING DRIVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628013506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VANDALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624712214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182834229 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROUGHTON | ||||||||
| AuthorizedOfficialFirstName: | GEORGIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6185331391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | A-00235-0004-A | 01 | IL | DHS LICENSE NUMBER | OTHER | 04035 | 05 | IL | MEDICAID | 6115207 | 01 | IL | BLUE CROSS | OTHER | A-00235-0003-A | 01 | IL | DHS LICENSE NUMBER | OTHER | A-00235-0002-A | 01 | IL | DHS LICENSE NUMBER | OTHER | A-00235-0001-A | 01 | IL | DHS LICENSE NUMBER | OTHER |