Healthcare Provider Details

I. General information

NPI: 1295906030
Provider Name (Legal Business Name): SHAWNEE CUSD 84
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 STATE HWY 3 N 3364 STATE HWY 3 N
WOLF LAKE IL
62998-0128
US

IV. Provider business mailing address

PO BOX 128 3364 STATE HWY. 3 N
WOLF LAKE IL
62998-0128
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-5709
  • Fax: 618-833-4171
Mailing address:
  • Phone: 618-833-5709
  • Fax: 618-833-4171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: DEBRA L SEALS
Title or Position: UNIT SECRETARY
Credential:
Phone: 618-833-5709