=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235344904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST JOSEPH OGDEN CHSD 305
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N MAIN
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61873-0890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-469-2586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 890
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61873-0890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPT
-----------------------------------------------------
Name | DR. VICTOR ZIMMERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-469-2586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number | 001
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------