Healthcare Provider Details

I. General information

NPI: 1962519405
Provider Name (Legal Business Name): PORTA COMM. UNIT DISTRICT 202
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17651 BLUEJAY ROAD
PETERSBURG IL
62675
US

IV. Provider business mailing address

17651 BLUEJAY ROAD
PETERSBURG IL
62675
US

V. Phone/Fax

Practice location:
  • Phone: 217-632-3803
  • Fax: 217-632-3221
Mailing address:
  • Phone: 217-632-3803
  • Fax: 217-632-3221

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: MATTHEW BRUW
Title or Position: SUPERINTENDENT
Credential:
Phone: 217-632-3803