Provider Demographics
NPI:1184091167
Name:SOUTHERN ILLINOIS COMMUNITY SUPPORT SERVICES
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS COMMUNITY SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6185-882-0066
Mailing Address - Street 1:300 E ILLINOIS ST
Mailing Address - Street 2:PO BOX 19
Mailing Address - City:NEW BADEN
Mailing Address - State:IL
Mailing Address - Zip Code:62265-1822
Mailing Address - Country:US
Mailing Address - Phone:618-588-7136
Mailing Address - Fax:618-588-4673
Practice Address - Street 1:300 E ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:NEW BADEN
Practice Address - State:IL
Practice Address - Zip Code:62265-1822
Practice Address - Country:US
Practice Address - Phone:618-588-7136
Practice Address - Fax:618-588-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities