Provider Demographics
NPI:1790136414
Name:FIVE STAR INDUSTRIES, INC.
Entity Type:Organization
Organization Name:FIVE STAR INDUSTRIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGELHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-542-5421
Mailing Address - Street 1:PO BOX 60
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0060
Mailing Address - Country:US
Mailing Address - Phone:618-542-5421
Mailing Address - Fax:618-790-9147
Practice Address - Street 1:1308 WELLS STREET RD
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-4171
Practice Address - Country:US
Practice Address - Phone:618-542-5421
Practice Address - Fax:618-790-9147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251C00000X
IL199100056S320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services