Provider Demographics
NPI:1932687944
Name:GOLD PLATE PROGRAM OF PERRY COUNTY
Entity Type:Organization
Organization Name:GOLD PLATE PROGRAM OF PERRY COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:ASBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-542-3511
Mailing Address - Street 1:PO BOX 345
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-0345
Mailing Address - Country:US
Mailing Address - Phone:618-542-3511
Mailing Address - Fax:618-542-2566
Practice Address - Street 1:721 N HICKORY ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832
Practice Address - Country:US
Practice Address - Phone:618-542-3511
Practice Address - Fax:618-542-2566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No253Z00000XAgenciesIn Home Supportive Care