Healthcare Provider Details

I. General information

NPI: 1154599165
Provider Name (Legal Business Name): ESWOOD CC GRADE SCH DIST 269
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 MAIN ST
LINDENWOOD IL
61049-7700
US

IV. Provider business mailing address

304 MAIN ST
LINDENWOOD IL
61049-7700
US

V. Phone/Fax

Practice location:
  • Phone: 815-393-4477
  • Fax:
Mailing address:
  • Phone: 815-393-4477
  • Fax:

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: DR. DWIGHT MAYBERRY
Title or Position: SUPER
Credential:
Phone: 815-393-4477