Provider Demographics
NPI:1104279967
Name:ROYAL LIVING CENTER
Entity type:Organization
Organization Name:ROYAL LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR/QIDP
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HECHENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:BSW MSP
Authorized Official - Phone:618-772-3522
Mailing Address - Street 1:200 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1933
Mailing Address - Country:US
Mailing Address - Phone:618-588-7295
Mailing Address - Fax:618-551-2091
Practice Address - Street 1:200 S 9TH ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1933
Practice Address - Country:US
Practice Address - Phone:618-588-7295
Practice Address - Fax:618-551-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-18
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL199400226S320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities