Provider Demographics
NPI:1932377652
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:GEORGIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROUGHTON
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 1:315 WESTGATE AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881
Practice Address - Country:US
Practice Address - Phone:618-548-2181
Practice Address - Fax:618-533-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04035Medicaid
ILA-00235-0001-AOtherDHS LICENSE NUMBER
IL6115207OtherBLUE CROSS
ILA-00235-0003-AOtherDHS LICENSE NUMBER
ILA-00235-0002-AOtherDHS LICENSE NUMBER
ILA-00235-0004-AOtherDHS LICENSE NUMBER
IL6115207OtherBLUE CROSS