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General NPI Number Information
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NPI Number | 1265066625
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Entity Type | Organization
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Legal Business Name | COUNTY OF HENRY
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Dates
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Enumeration Date | 02/25/2020
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Last Update Date | 02/25/2020
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Provider Practice Location Address
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Address Line | 110 N BURR BLVD
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City | KEWANEE
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State | IL
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Zip | 61443-2214
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Country | US
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Telephone | 309-852-0197
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Fax | 309-852-0595
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Provider Business Mailing Address
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Address Line | 110 N BURR BLVD
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City | KEWANEE
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State | IL
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Zip | 61443-2214
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Country | US
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Telephone | 309-852-0197
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Fax | 309-852-0595
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Authorized Official
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Title or Position | CREDENTIALING REPRESENTATIVE
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Name | TARA LAFOLLETTE
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Credential |
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Telephone | 309-852-0197
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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