Provider Demographics
NPI:1083729909
Name:WILLIAMSON COUNTY PROGRAMS ON AGING HOME HEALTH
Entity Type:Organization
Organization Name:WILLIAMSON COUNTY PROGRAMS ON AGING HOME HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:BOESTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:618-942-6933
Mailing Address - Street 1:204 RUSHING DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3713
Mailing Address - Country:US
Mailing Address - Phone:618-993-5165
Mailing Address - Fax:618-993-5721
Practice Address - Street 1:204 RUSHING DR
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3713
Practice Address - Country:US
Practice Address - Phone:618-993-5165
Practice Address - Fax:618-993-5721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1003771251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid
IL=========Medicaid