=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124298690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARBONDALE COMMUNITY HIGH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2008
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 S GIANT CITY RD
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62902-5042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-457-4722
-----------------------------------------------------
Fax | 618-457-3353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 S GIANT CITY RD
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62902-5042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-457-4722
-----------------------------------------------------
Fax | 618-457-3353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL OFFICER
-----------------------------------------------------
Name | MR. STEVE KOSCO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-457-4722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1000X
-----------------------------------------------------
Taxonomy Name | Student Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------