Healthcare Provider Details

I. General information

NPI: 1295704021
Provider Name (Legal Business Name): MENARD COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N 4TH SUITE A
PETERSBURG IL
62675
US

IV. Provider business mailing address

1120 N 4TH SUITE A
PETERSBURG IL
62675
US

V. Phone/Fax

Practice location:
  • Phone: 217-632-2984
  • Fax: 217-632-3675
Mailing address:
  • Phone: 217-632-2984
  • Fax: 217-632-3675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number1002096
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number147070
License Number StateIL

VIII. Authorized Official

Name: CHERYL LEE
Title or Position: ADMINISTRATOR
Credential: M.S.
Phone: 217-632-2984