Provider Demographics
NPI:1427236900
Name:CARDINAL HOUSE INC
Entity type:Organization
Organization Name:CARDINAL HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX DIR SE
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:PT QMRP
Authorized Official - Phone:618-833-7756
Mailing Address - Street 1:PO BOX 622
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-0622
Mailing Address - Country:US
Mailing Address - Phone:618-833-7756
Mailing Address - Fax:618-833-7806
Practice Address - Street 1:200 DOUGLAS STREET
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906
Practice Address - Country:US
Practice Address - Phone:618-833-7756
Practice Address - Fax:618-833-7756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL965010320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities