Provider Demographics
NPI:1194856203
Name:SULLIVAN COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:SULLIVAN COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MS IN HEALTH ED &MGT
Authorized Official - Phone:660-265-4141
Mailing Address - Street 1:101 HAWTHORNE DR
Mailing Address - Street 2:PO BOX 129
Mailing Address - City:MILAN
Mailing Address - State:MO
Mailing Address - Zip Code:63556-1017
Mailing Address - Country:US
Mailing Address - Phone:660-265-4141
Mailing Address - Fax:660-265-3891
Practice Address - Street 1:101 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MO
Practice Address - Zip Code:63556-1017
Practice Address - Country:US
Practice Address - Phone:660-265-4141
Practice Address - Fax:660-265-3891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO12603007251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management