Provider Demographics
NPI:1457033763
Name:RAINBOW CAFE LGBTQ CENTER
Entity Type:Organization
Organization Name:RAINBOW CAFE LGBTQ CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VINE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:915-217-8288
Mailing Address - Street 1:118 N ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1450
Mailing Address - Country:US
Mailing Address - Phone:618-525-9922
Mailing Address - Fax:
Practice Address - Street 1:118 N ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1450
Practice Address - Country:US
Practice Address - Phone:618-525-9922
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-04
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health