Provider Demographics
NPI:1114140373
Name:COMMUNITY RESIDENTIAL CENTERS INC
Entity Type:Organization
Organization Name:COMMUNITY RESIDENTIAL CENTERS INC
Other - Org Name:ST MARYS SQUARE LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS LNHA
Authorized Official - Phone:309-343-4101
Mailing Address - Street 1:239 S CHERRY STREET
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401
Mailing Address - Country:US
Mailing Address - Phone:309-343-4101
Mailing Address - Fax:309-343-4106
Practice Address - Street 1:239 S CHERRY STREET
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401
Practice Address - Country:US
Practice Address - Phone:309-343-4101
Practice Address - Fax:309-343-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL003406315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid