Provider Demographics
NPI:1578729810
Name:HOME AND ENVIRONMENTS FOR LIVING AND PROGRAMS
Entity Type:Organization
Organization Name:HOME AND ENVIRONMENTS FOR LIVING AND PROGRAMS
Other - Org Name:PIASA MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROOKSHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-529-9632
Mailing Address - Street 1:40 ADLOFF LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4441
Mailing Address - Country:US
Mailing Address - Phone:217-529-9632
Mailing Address - Fax:217-529-9635
Practice Address - Street 1:110 N ALBY COURT
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035
Practice Address - Country:US
Practice Address - Phone:618-466-9243
Practice Address - Fax:618-466-9517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038422315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid