Provider Demographics
NPI:1104047208
Name:CLAY COUNTY REHABILITATION CENTER, INC.
Entity type:Organization
Organization Name:CLAY COUNTY REHABILITATION CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-662-4916
Mailing Address - Street 1:530 W 4TH ST
Mailing Address - Street 2:P.O. BOX 659
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-1213
Mailing Address - Country:US
Mailing Address - Phone:618-662-4916
Mailing Address - Fax:618-662-9354
Practice Address - Street 1:530 W 4TH ST
Practice Address - Street 2:
Practice Address - City:FLORA
Practice Address - State:IL
Practice Address - Zip Code:62839-1213
Practice Address - Country:US
Practice Address - Phone:618-662-4916
Practice Address - Fax:618-662-9354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0371OtherDAY TRAINING AGENCY ID