Healthcare Provider Details

I. General information

NPI: 1790785186
Provider Name (Legal Business Name): COUNTY OF LOGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 3RD ST
LINCOLN IL
62656-0508
US

IV. Provider business mailing address

109 3RD ST P.O. BOX 508
LINCOLN IL
62656-0508
US

V. Phone/Fax

Practice location:
  • Phone: 217-735-2317
  • Fax: 217-732-6943
Mailing address:
  • Phone: 217-735-2317
  • Fax: 217-732-6943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberIL1001866
License Number StateIL

VIII. Authorized Official

Name: MR. MARK HILLIARD
Title or Position: ADMINISTRATOR
Credential:
Phone: 217-735-2317