Provider Demographics
NPI:1356640346
Name:TRI-COUNTY ALCOHOL AND DRUG SERVICES LLC
Entity Type:Organization
Organization Name:TRI-COUNTY ALCOHOL AND DRUG SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, CADC
Authorized Official - Phone:309-752-9740
Mailing Address - Street 1:926 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61244-2138
Mailing Address - Country:US
Mailing Address - Phone:309-752-9740
Mailing Address - Fax:309-752-9744
Practice Address - Street 1:926 15TH AVE
Practice Address - Street 2:
Practice Address - City:EAST MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61244-2138
Practice Address - Country:US
Practice Address - Phone:309-752-9740
Practice Address - Fax:309-752-9744
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRI-COUNTY ALCOHOL AND DRUG SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-8601-0002-A261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2575259OtherCIGNA BEHAVIORAL HEALTH
IL9510564OtherMULTIPLAN