Healthcare Provider Details

I. General information

NPI: 1598873176
Provider Name (Legal Business Name): DIETERICH COMM UNIT 30
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S. PINE
DIETERICH IL
62424
US

IV. Provider business mailing address

205 S. PINE PO BOX 107
DIETERICH IL
62424
US

V. Phone/Fax

Practice location:
  • Phone: 217-925-5249
  • Fax: 217-925-5447
Mailing address:
  • Phone: 217-925-5249
  • Fax: 217-925-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE OWEN
Title or Position: SUPERINTENDENT
Credential:
Phone: 217-925-5249