Healthcare Provider Details

I. General information

NPI: 1336272764
Provider Name (Legal Business Name): COLEMAN TRI-COUNTY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

# 22 VETERANS DRIVE
HARRISBURG IL
62946
US

IV. Provider business mailing address

# 22 VETERANS DRIVE
HARRISBURG IL
62946
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-0275
  • Fax: 618-252-2389
Mailing address:
  • Phone: 618-252-0275
  • Fax: 618-252-2389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateIL

VIII. Authorized Official

Name: PAMELA MORSE
Title or Position: ACCOUNTANT
Credential:
Phone: 618-252-0275