Provider Demographics
NPI:1134349202
Name:LAWRENCE COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:LAWRENCE COUNTY HEALTH DEPARTMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-943-3302
Mailing Address - Street 1:PO BOX 516
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62439-0516
Mailing Address - Country:US
Mailing Address - Phone:618-943-3302
Mailing Address - Fax:618-943-3657
Practice Address - Street 1:RR 3 BOX 414
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62439-9499
Practice Address - Country:US
Practice Address - Phone:618-943-3302
Practice Address - Fax:618-943-3657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid