MEDICARE: SOUTHWESTERN ILLINOIS COLLEGE PROGRAMS FOR OLDER PSREONS

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
1	251K00000X	Public Health or Welfare Agency		IL

General Provider Information

NPI Number	:	1326041708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWESTERN ILLINOIS COLLEGE PROGRAMS FOR OLDER PSREONS

Provider Business Mailing Address
First Line	:	201 N CHURCH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-4005
Country	:	US
Telephone Number	:	618-234-4410
Fax Number	:	618-234-8634

Provider Business Practice Location Address
First Line	:	201 N CHURCH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62220-4005
Country	:	US
Telephone Number	:	618-234-4410
Fax Number	:	618-234-8634

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. VICKI ROSE
Credential	:
Telephone Number	:	618-234-4410

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/21/2022

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