Basic Information
| Provider Information | |||||||||
| NPI: | 1740458462 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY RESOURCE CENTER | ||||||||
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| 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: | 867 MLK DRIVE | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628015618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | BROUGHTON | ||||||||
| AuthorizedOfficialFirstName: | GEORGIANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6185331391 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 04035 | 05 | IL | MEDICAID |