NPIMap

Organization Active NPI

Community Residential Centers Inc

Doing business as St Marys Square Living Center

  • Intellectual Disabilities Intermediate Care Facility
  • Galesburg, IL
National Provider Identifier
1114140373
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
003406 Issued in IL
Legal business name
COMMUNITY RESIDENTIAL CENTERS INC
Doing business as
St Marys Square Living Center
Practice address
239 S Cherry Street
Galesburg, IL 61401
Phone
(309) 343-4101
Fax
(309) 343-4106
NPI assigned
Apr 10, 2007
Last updated
Aug 22, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Bobby D Dillard, MS LNHA
Title
Administrator
Phone
(309) 343-4101

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 003406 IL Primary

Addresses

Primary practice location

239 S Cherry Street
Galesburg, IL 61401

Mailing address

239 S Cherry Street
Galesburg, IL 61401
Phone (309) 343-4101

Other names 1

  • St Marys Square Living Center Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Community Residential Centers Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176163200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1114140373",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "239 S CHERRY STREET",
            "city": "GALESBURG",
            "state": "IL",
            "postal_code": "61401",
            "telephone_number": "309-343-4101",
            "fax_number": "309-343-4106"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "239 S CHERRY STREET",
            "city": "GALESBURG",
            "state": "IL",
            "postal_code": "61401",
            "telephone_number": "309-343-4101",
            "fax_number": "309-343-4106"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY RESIDENTIAL CENTERS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-10",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "DILLARD",
        "authorized_official_first_name": "BOBBY",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "309-343-4101",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MS LNHA"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "IL",
            "license": "003406",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St Marys Square Living Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Galesburg, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.