1619144169 NPI number — COLES COUNTY MENTAL HEALTH ASSOCIATION INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619144169 NPI number — COLES COUNTY MENTAL HEALTH ASSOCIATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLES COUNTY MENTAL HEALTH ASSOCIATION INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIFELINKS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619144169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
750 BROADWAY AVE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTOON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61938-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-238-5700
Provider Business Mailing Address Fax Number:
217-238-5767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 BROADWAY AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTOON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61938-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-238-5700
Provider Business Practice Location Address Fax Number:
217-238-5767
Provider Enumeration Date:
05/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCESS CENTER COORDINATOR
Authorized Official Telephone Number:
217-238-5700

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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