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General NPI Number Information
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NPI Number | 1174796734
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Entity Type | Organization
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Legal Business Name | MADISON COUNTY URBAN LEAGUE
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Dates
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Enumeration Date | 04/03/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 500 MADISON AVE
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City | MADISON
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State | IL
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Zip | 62060-1414
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Country | US
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Telephone | 618-876-9145
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Fax | 618-452-5392
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Provider Business Mailing Address
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Address Line | PO BOX 135
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City | MADISON
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State | IL
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Zip | 62060-0135
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Country | US
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Telephone | 618-876-9145
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Fax | 618-452-5392
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Authorized Official
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Title or Position | NURSE
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Name | ANN LOUISE WALKINGTON
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Credential |
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Telephone | 618-876-9145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | IL
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