Provider Demographics
NPI:1184623332
Name:POPE COUNTY CARE HOME INC
Entity type:Organization
Organization Name:POPE COUNTY CARE HOME INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:W
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-549-8331
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:GOLCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:62938-0488
Mailing Address - Country:US
Mailing Address - Phone:618-683-7711
Mailing Address - Fax:618-683-7721
Practice Address - Street 1:216 E ROSALIE
Practice Address - Street 2:
Practice Address - City:GOLCONDA
Practice Address - State:IL
Practice Address - Zip Code:62938
Practice Address - Country:US
Practice Address - Phone:618-683-7711
Practice Address - Fax:618-683-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-19
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========801Medicaid
IL=========801Medicaid