Provider Demographics
NPI:1023643772
Name:SUPPORTING COMMUNITY INDEPENDENCE
Entity type:Organization
Organization Name:SUPPORTING COMMUNITY INDEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SAHURI
Authorized Official - Suffix:
Authorized Official - Credentials:QIDP,RN
Authorized Official - Phone:618-806-4344
Mailing Address - Street 1:1 POLO GROUNDS CT
Mailing Address - Street 2:
Mailing Address - City:BETHALTO
Mailing Address - State:IL
Mailing Address - Zip Code:62010-2623
Mailing Address - Country:US
Mailing Address - Phone:618-806-4344
Mailing Address - Fax:
Practice Address - Street 1:1 POLO GROUNDS CT
Practice Address - Street 2:
Practice Address - City:BETHALTO
Practice Address - State:IL
Practice Address - Zip Code:62010-2623
Practice Address - Country:US
Practice Address - Phone:618-806-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities