1164476115 NPI number — RIVERBEND HEAD START & FAMILY SERVICES

Table of content: (NPI 1164476115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164476115 NPI number — RIVERBEND HEAD START & FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVERBEND HEAD START & FAMILY SERVICES
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:
Provider Other Organization Name Type Code:
6
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:
1164476115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 LANDMARKS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62002-7304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-463-5927
Provider Business Mailing Address Fax Number:
618-463-5965

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3550 COLLEGE AVE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
ALTON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62002-7304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-463-5927
Provider Business Practice Location Address Fax Number:
618-463-5965
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOFFET
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
618-463-5927

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3741717016 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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