Provider Demographics
NPI:1093930620
Name:CENTERVILLE HOUSE
Entity Type:Organization
Organization Name:CENTERVILLE HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:HOLTSCHLAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-228-9268
Mailing Address - Street 1:3325 GHOST HOLLOW ROAD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305
Mailing Address - Country:US
Mailing Address - Phone:217-228-9268
Mailing Address - Fax:
Practice Address - Street 1:7 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-6855
Practice Address - Country:US
Practice Address - Phone:573-221-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services