Provider Demographics
NPI:1407283906
Name:BOONE COUNTY COUNCIL ON AGING
Entity Type:Organization
Organization Name:BOONE COUNTY COUNCIL ON AGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-544-9893
Mailing Address - Street 1:2141 HENRY LUCKOW LN
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-1700
Mailing Address - Country:US
Mailing Address - Phone:815-544-9893
Mailing Address - Fax:815-547-7373
Practice Address - Street 1:2141 HENRY LUCKOW LN
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-1700
Practice Address - Country:US
Practice Address - Phone:815-544-9893
Practice Address - Fax:815-547-7373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-30
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILINH1001001OtherSTATE OF ILLINOIS CCP CONTRACT