Provider Demographics
NPI:1891910709
Name:ALCOHOLIC REHABILITATION COMMUNITY HOME
Entity Type:Organization
Organization Name:ALCOHOLIC REHABILITATION COMMUNITY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:618-877-4987
Mailing Address - Street 1:1313 21ST ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4756
Mailing Address - Country:US
Mailing Address - Phone:618-877-4987
Mailing Address - Fax:618-877-4930
Practice Address - Street 1:1313 21ST ST
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4756
Practice Address - Country:US
Practice Address - Phone:618-877-4987
Practice Address - Fax:618-877-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA06870001A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA06870001AOtherDHS - OASA