Basic Information
| Provider Information | |||||||||
| NPI: | 1811441371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUMAN RESOURCES CENTER OF EDGAR AND CLARK COUNTIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 E COURT ST | ||||||||
| Address2: | P. O. BOX 1118 | ||||||||
| City: | PARIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619442210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174654118 | ||||||||
| FaxNumber: | 2174631899 | ||||||||
| Practice Location | |||||||||
| Address1: | 118 E COURT ST | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619442210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174654118 | ||||||||
| FaxNumber: | 2174631899 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2016 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | POLKY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2174654118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 1407014376 | 05 | IL | MEDICAID | 1790942761 | 05 | IL | MEDICAID | 1104088624 | 05 | IL | MEDICAID | 1205883428 | 05 | IL | MEDICAID | 1184881773 | 05 | IL | MEDICAID | 1437316023 | 05 | IL | MEDICAID |