Healthcare Provider Details

I. General information

NPI: 1497889554
Provider Name (Legal Business Name): COUNTY OF FULTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 EAST MONROE STREET
CUBA IL
61427-0200
US

IV. Provider business mailing address

PO BOX 200 625 EAST MONROE STREET
CUBA IL
61427-0200
US

V. Phone/Fax

Practice location:
  • Phone: 309-785-5012
  • Fax: 309-785-5376
Mailing address:
  • Phone: 309-785-5012
  • Fax: 309-785-5376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0014290
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0014290
License Number StateIL

VIII. Authorized Official

Name: MRS. MARTHA J DANIELSON
Title or Position: ADMINISTRATOR
Credential: LNHA
Phone: 309-785-5012