Provider Demographics
NPI:1760658926
Name:BOND COUNTY SENIOR CITIZENS CENTER
Entity Type:Organization
Organization Name:BOND COUNTY SENIOR CITIZENS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DESTREICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-664-1465
Mailing Address - Street 1:305 S THIRD ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62246
Mailing Address - Country:US
Mailing Address - Phone:618-664-1465
Mailing Address - Fax:618-664-1478
Practice Address - Street 1:305 S THIRD ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246
Practice Address - Country:US
Practice Address - Phone:618-664-1465
Practice Address - Fax:618-664-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid