Provider Demographics
NPI:1235580564
Name:HAZEL BLAND PROMISE CENTER
Entity Type:Organization
Organization Name:HAZEL BLAND PROMISE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY SUPPORT UNIT DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-274-3500
Mailing Address - Street 1:2900 STATE ST
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-2234
Mailing Address - Country:US
Mailing Address - Phone:618-274-3500
Mailing Address - Fax:
Practice Address - Street 1:2900 STATE ST
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-2234
Practice Address - Country:US
Practice Address - Phone:618-274-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL199200170S320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities