Provider Demographics
NPI:1891944393
Name:HENDERSON COUNTY
Entity Type:Organization
Organization Name:HENDERSON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-627-2812
Mailing Address - Street 1:P O BOX 220
Mailing Address - Street 2:208 WEST ELM STREET
Mailing Address - City:GLADSTONE
Mailing Address - State:IL
Mailing Address - Zip Code:61437
Mailing Address - Country:UM
Mailing Address - Phone:309-627-2812
Mailing Address - Fax:309-627-2793
Practice Address - Street 1:208 WEST ELM STREET
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:IL
Practice Address - Zip Code:61437
Practice Address - Country:UM
Practice Address - Phone:309-627-2812
Practice Address - Fax:309-627-2793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1001502251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid