Basic Information
| Provider Information | |||||||||
| NPI: | 1932377652 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY RESOURCE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S LOCUST ST | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628013506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185331391 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 WESTGATE AVE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185482181 | ||||||||
| FaxNumber: | 6185330012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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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 | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 04035 | 05 | IL | MEDICAID | A-00235-0001-A | 01 | IL | DHS LICENSE NUMBER | OTHER | 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-00235-0004-A | 01 | IL | DHS LICENSE NUMBER | OTHER |