Provider Demographics
NPI:1801000922
Name:MONTGOMERY CARLINVILLE REGION OF MSSE
Entity Type:Organization
Organization Name:MONTGOMERY CARLINVILLE REGION OF MSSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-824-8121
Mailing Address - Street 1:116 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-2230
Mailing Address - Country:US
Mailing Address - Phone:217-824-8121
Mailing Address - Fax:217-824-8199
Practice Address - Street 1:116 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-2230
Practice Address - Country:US
Practice Address - Phone:217-824-8121
Practice Address - Fax:217-824-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid