Provider Demographics
NPI:1518246776
Name:COMMUNITY RESOURCE CENTER INC.
Entity Type:Organization
Organization Name:COMMUNITY RESOURCE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GEORGIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-533-1391
Mailing Address - Street 1:101 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3506
Mailing Address - Country:US
Mailing Address - Phone:618-533-1391
Mailing Address - Fax:618-533-0012
Practice Address - Street 1:904 E. MARTIN LUTHER KING DRIVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-6280
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:618-533-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04035251S00000X
ILA-0205-0001-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04035Medicaid
671700Medicare UPIN