Provider Demographics
NPI:1508235060
Name:SOUTHEASTERN IL AGENCY ON AGING, INC
Entity Type:Organization
Organization Name:SOUTHEASTERN IL AGENCY ON AGING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:BS,BA
Authorized Official - Phone:618-262-2306
Mailing Address - Street 1:516 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CARMEL
Mailing Address - State:IL
Mailing Address - Zip Code:62863-1558
Mailing Address - Country:US
Mailing Address - Phone:618-262-2306
Mailing Address - Fax:618-262-4967
Practice Address - Street 1:516 N MARKET ST
Practice Address - Street 2:
Practice Address - City:MOUNT CARMEL
Practice Address - State:IL
Practice Address - Zip Code:62863-1558
Practice Address - Country:US
Practice Address - Phone:618-262-2306
Practice Address - Fax:618-262-4967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable