1629455019 NPI number — CENTRAL EAST ALCOHOLISM AND DRUG COUNCIL

Table of content: (NPI 1629455019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629455019 NPI number — CENTRAL EAST ALCOHOLISM AND DRUG COUNCIL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL EAST ALCOHOLISM AND DRUG COUNCIL
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:
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:
1629455019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
635 DIVISION ST
Provider Second Line Business Mailing Address:
P.O. BOX 532
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61920-1902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-348-8108
Provider Business Mailing Address Fax Number:
217-345-6794

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 S MORGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62565-2241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-348-8108
Provider Business Practice Location Address Fax Number:
217-345-6794
Provider Enumeration Date:
05/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PERDIEU
Authorized Official First Name:
TERESSA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
217-348-8108

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  A-0634-0002-A , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CA-0631-0002-A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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