Provider Demographics
NPI:1114035722
Name:GEORGETOWN RIDGE FARM 4
Entity Type:Organization
Organization Name:GEORGETOWN RIDGE FARM 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-662-8488
Mailing Address - Street 1:400 W WEST ST
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61846-1846
Mailing Address - Country:US
Mailing Address - Phone:217-662-8488
Mailing Address - Fax:217-662-3402
Practice Address - Street 1:400 W WEST ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IL
Practice Address - Zip Code:61846-1846
Practice Address - Country:US
Practice Address - Phone:217-662-8488
Practice Address - Fax:217-662-3402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid