Provider Demographics
NPI:1629132410
Name:COUNTY OF LAWRENCE HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:COUNTY OF LAWRENCE HEALTH DEPARTMENT
Other - Org Name:LAWRENCE COUNTY HEALTH DEPARTMENT RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-943-3302
Mailing Address - Street 1:2101 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-2027
Mailing Address - Country:US
Mailing Address - Phone:618-943-3302
Mailing Address - Fax:
Practice Address - Street 1:2101 JAMES ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-2027
Practice Address - Country:US
Practice Address - Phone:618-943-3302
Practice Address - Fax:618-943-6409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========007Medicaid
143951Medicare ID - Type UnspecifiedRIVERBEND
IL=========007Medicaid