MEDICARE: SHAWNEE C U SCHOOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS1000X	Student Health Clinic/Center		IL

General Provider Information

NPI Number	:	1164696639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAWNEE C U SCHOOL

Provider Business Mailing Address
First Line	:	PO BOX 128
Second Line	:	3365 STATE HWY 3 N
City	:	WOLF LAKE
State	:	IL
Zip	:	62998-0128
Country	:	US
Telephone Number	:	618-833-5709
Fax Number	:	618-833-4171

Provider Business Practice Location Address
First Line	:	3365 STATE HWY 3 N
Second Line	:	3365 STATE HWY 3 N
City	:	WOLF LAKE
State	:	IL
Zip	:	62998-0128
Country	:	US
Telephone Number	:	618-833-5709
Fax Number	:	618-833-4171

Authorized Official
Title or Position	:	UNIT SECRETARY
Name	:	DEBRA L SEALS
Credential	:
Telephone Number	:	618-833-5709

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	04/20/2008

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Directions to “SHAWNEE C U SCHOOL ” Practice Location

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