Provider Demographics
NPI:1225719974
Name:SENIOR PALACE ADULT CARE
Entity Type:Organization
Organization Name:SENIOR PALACE ADULT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ADULT DAYCARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-651-8351
Mailing Address - Street 1:4734 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46327-1530
Mailing Address - Country:US
Mailing Address - Phone:319-651-8351
Mailing Address - Fax:
Practice Address - Street 1:27815 S STONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-8001
Practice Address - Country:US
Practice Address - Phone:319-651-8351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities