Provider Demographics
NPI:1841468568
Name:COMMUNITY RESOURCE CENTER INC
Entity type:Organization
Organization Name:COMMUNITY RESOURCE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-533-1391
Mailing Address - Street 1:101 S LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-3506
Mailing Address - Country:US
Mailing Address - Phone:618-533-1391
Mailing Address - Fax:618-533-0012
Practice Address - Street 1:904 EAST MARTIN LUTHER KING DRIVE
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-533-1391
Practice Address - Fax:618-533-0012
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY RESOURCE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-15
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04035Medicaid
IL04035Medicaid