Healthcare Provider Details

I. General information

NPI: 1881724565
Provider Name (Legal Business Name): SPRING GARDEN COMMUNITY CONSOLIDATED SCHOOL DISTRICT #178
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14975 E BAKERVILLE RD
MOUNT VERNON IL
62864
US

IV. Provider business mailing address

14975 E BAKERVILLE RD
MOUNT VERNON IL
62864
US

V. Phone/Fax

Practice location:
  • Phone: 618-244-8070
  • Fax: 618-244-8071
Mailing address:
  • Phone: 618-244-8070
  • Fax: 618-244-8071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: MRS. NIKKI DAWN STRAIN
Title or Position: ADMINISTRATIVE ASSISTANT
Credential:
Phone: 618-244-8070