Provider Demographics
NPI:1255587408
Name:HOME AND ENVIRONMENTS FOR LIVING AND PROGRAMS
Entity type:Organization
Organization Name:HOME AND ENVIRONMENTS FOR LIVING AND PROGRAMS
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 STE 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-4496
Mailing Address - Country:US
Mailing Address - Phone:217-529-9632
Mailing Address - Fax:217-529-9635
Practice Address - Street 1:50 ADLOFF LN
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4402
Practice Address - Country:US
Practice Address - Phone:217-786-3109
Practice Address - Fax:217-786-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1870187315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========010Medicaid