Provider Demographics
NPI:1235323841
Name:PARENTS AND FRIENDS OF SLC
Entity Type:Organization
Organization Name:PARENTS AND FRIENDS OF SLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUENENFELDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-277-7730
Mailing Address - Street 1:1450 CASEYVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-4517
Mailing Address - Country:US
Mailing Address - Phone:618-277-7730
Mailing Address - Fax:618-277-5423
Practice Address - Street 1:1450 CASEYVILLE AVE
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-4517
Practice Address - Country:US
Practice Address - Phone:618-277-7730
Practice Address - Fax:618-277-5423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1725481313M00000X
320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid