Healthcare Provider Details

I. General information

NPI: 1770614877
Provider Name (Legal Business Name): DIAMOND LAKE SCH DIST 76
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25807 N DIAMOND LAKE RD
MUNDELEIN IL
60060-9415
US

IV. Provider business mailing address

25807 N DIAMOND LAKE RD
MUNDELEIN IL
60060-9415
US

V. Phone/Fax

Practice location:
  • Phone: 847-566-9221
  • Fax: 847-566-5689
Mailing address:
  • Phone: 847-566-9221
  • Fax: 847-566-5689

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: COLETTE FORD
Title or Position: BUSINESS MANAGER
Credential:
Phone: 847-566-9221