MEDICARE: MOMENCE COMMUNITY UNIT SCHOOL DISTRICT #1

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1790800597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMENCE COMMUNITY UNIT SCHOOL DISTRICT #1

Provider Business Mailing Address
First Line	:	415 N DIXIE HIGHWAY
Second Line	:
City	:	MOMENCE
State	:	IL
Zip	:	60954
Country	:	US
Telephone Number	:	815-472-3501
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 N DIXIE HIGHWAY
Second Line	:
City	:	MOMENCE
State	:	IL
Zip	:	60954
Country	:	US
Telephone Number	:	815-472-3501
Fax Number	:

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	DR. PHIL SMITH
Credential	:
Telephone Number	:	815-472-3501

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	08/22/2020

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