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NPI Code Detail

MEDICARE: COUNTY OF HENRY

MEDICARE: COUNTY OF HENRY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QR1300XRural Health Clinic/Center

General Provider Information

NPI Number : 1265066625
Entity Type Code : Organization
Provider Name (Legal Business Name) : COUNTY OF HENRY
Provider Business Mailing Address
First Line : 110 N BURR BLVD
Second Line :
City : KEWANEE
State : IL
Zip : 61443-2214
Country : US
Telephone Number : 309-852-0197
Fax Number : 309-852-0595
Provider Business Practice Location Address
First Line : 110 N BURR BLVD
Second Line :
City : KEWANEE
State : IL
Zip : 61443-2214
Country : US
Telephone Number : 309-852-0197
Fax Number : 309-852-0595
Authorized Official
Title or Position : CREDENTIALING REPRESENTATIVE
Name : TARA LAFOLLETTE
Credential :
Telephone Number : 309-852-0197
Provider Enumeration Date : 02/25/2020
Last Update Date : 02/25/2020

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Directions to “COUNTY OF HENRY ” Practice Location

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