Provider Demographics
NPI:1841317500
Name:TRI COUNTY SP ED JNT AGREEMENT
Entity type:Organization
Organization Name:TRI COUNTY SP ED JNT AGREEMENT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:H.
Authorized Official - Middle Name:REBECCA
Authorized Official - Last Name:CANTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-568-1321
Mailing Address - Street 1:114 S. 8TH STREET
Mailing Address - Street 2:P.O. BOX 130
Mailing Address - City:ELKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62924-0130
Mailing Address - Country:US
Mailing Address - Phone:618-568-1321
Mailing Address - Fax:618-568-1152
Practice Address - Street 1:114 S. 8TH STREET
Practice Address - Street 2:
Practice Address - City:ELKVILLE
Practice Address - State:IL
Practice Address - Zip Code:62932-0130
Practice Address - Country:US
Practice Address - Phone:618-568-1321
Practice Address - Fax:618-568-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL376022272001Medicaid