Provider Demographics
NPI:1891819744
Name:TRI COUNTY SP ED JNT AGREEMENT
Entity Type:Organization
Organization Name:TRI COUNTY SP ED JNT AGREEMENT
Other - Org Name:COMM UNIT SCHOOL DIST 186 TRI COUNTY SP ED JNT AGREEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF SPECIAL EDUCATION
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-684-2109
Mailing Address - Street 1:1725 SHOMAKER DR
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2507
Mailing Address - Country:US
Mailing Address - Phone:618-684-2109
Mailing Address - Fax:
Practice Address - Street 1:1725 SHOMAKER DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2507
Practice Address - Country:US
Practice Address - Phone:618-684-2109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-18
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid