Provider Demographics
NPI:1346369642
Name:PIASA MANOR
Entity Type:Organization
Organization Name:PIASA MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QMRP
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-466-9242
Mailing Address - Street 1:110 N ALBY CT
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1963
Mailing Address - Country:US
Mailing Address - Phone:618-466-9242
Mailing Address - Fax:618-466-9517
Practice Address - Street 1:110 N ALBY CT
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1963
Practice Address - Country:US
Practice Address - Phone:618-466-9242
Practice Address - Fax:618-466-9517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038422320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371272004Medicaid
IL371272004Medicaid