Healthcare Provider Details

I. General information

NPI: 1689875643
Provider Name (Legal Business Name): BREMEN COMMUNITY HIGH SCHOOL DISTRICT 228
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15233 PULASKI RD
MIDLOTHIAN IL
60445-3755
US

IV. Provider business mailing address

15233 PULASKI RD
MIDLOTHIAN IL
60445-3755
US

V. Phone/Fax

Practice location:
  • Phone: 708-389-1175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: THOMAS O MALLEY
Title or Position: DIRECTOR OF FINANCIAL SERVICES
Credential:
Phone: 708-389-1175