1790042000 NPI number — CHRISTIAN SOCIAL SERVICES OF ILLINOIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790042000 NPI number — CHRISTIAN SOCIAL SERVICES OF ILLINOIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTIAN SOCIAL SERVICES OF ILLINOIS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CATHOLIC SOCIAL SERVICES OF SOUTHERN ILLINOIS
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790042000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
214 S UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62901-2925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8601 W MAIN ST
Provider Second Line Business Practice Location Address:
STE. 201
Provider Business Practice Location Address City Name:
BELLEVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62223-1719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-394-5900
Provider Business Practice Location Address Fax Number:
618-394-5909
Provider Enumeration Date:
04/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BECK
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
618-688-1161

Provider Taxonomy Codes

  • Taxonomy code: 253J00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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