Provider Demographics
NPI:1609228808
Name:MOULTRIE COUNTY BEACON, INC.
Entity Type:Organization
Organization Name:MOULTRIE COUNTY BEACON, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-728-7396
Mailing Address - Street 1:401 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1883
Mailing Address - Country:US
Mailing Address - Phone:217-728-7396
Mailing Address - Fax:217-728-2217
Practice Address - Street 1:401 W WATER ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1883
Practice Address - Country:US
Practice Address - Phone:217-728-7396
Practice Address - Fax:217-728-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services