Provider Demographics
NPI:1295704021
Name:MENARD COUNTY HEALTH DEPARTMENT
Entity type:Organization
Organization Name:MENARD COUNTY HEALTH DEPARTMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:217-632-2984
Mailing Address - Street 1:1120 N 4TH
Mailing Address - Street 2:SUITE A
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675
Mailing Address - Country:US
Mailing Address - Phone:217-632-2984
Mailing Address - Fax:217-632-3675
Practice Address - Street 1:1120 N 4TH
Practice Address - Street 2:SUITE A
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675
Practice Address - Country:US
Practice Address - Phone:217-632-2984
Practice Address - Fax:217-632-3675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MENARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-15
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1002096251E00000X
IL147070251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid