=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275701245
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER RIDGE COMM SCH DIST 210
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2008
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4141 IL ROUTE 84 S
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61041-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-858-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4141 IL ROUTE 84 S
-----------------------------------------------------
City | HANOVER
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61041-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-858-9005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMIN
-----------------------------------------------------
Name | PETE SCARANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-858-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------