Provider Demographics
NPI:1053455667
Name:CENTERSTONE OF ILLINOIS, INC
Entity Type:Organization
Organization Name:CENTERSTONE OF ILLINOIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-937-6483
Mailing Address - Street 1:902 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-2210
Mailing Address - Country:US
Mailing Address - Phone:618-937-6483
Mailing Address - Fax:618-937-1440
Practice Address - Street 1:902 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-2210
Practice Address - Country:US
Practice Address - Phone:618-937-6483
Practice Address - Fax:618-937-1440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL351786086001Medicaid
ID359629323001Medicaid
IL=========018Medicaid
IL=========004Medicaid
IL=========007Medicaid
IL=========011Medicaid
IL=========017Medicaid
IL351786086001Medicaid
ID359629323001Medicaid
ID=========015Medicaid
IL=========013Medicaid
IL=========001Medicaid
IL=========016Medicaid
IL=========012Medicaid