Basic Information
| Provider Information | |||||||||
| NPI: | 1801252994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHELBY COUNTY COMMUNITY SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 W SOUTH 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625659595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177745587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1810 W SOUTH 3RD ST | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625659595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177745587 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2016 | ||||||||
| LastUpdateDate: | 01/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | COLCLASURE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2177745587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 320800000X | 04121 | IL | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 320900000X | 199100020S | IL | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 04121 | 05 | IL | MEDICAID |