=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336313071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARL SANDBURG COLLEGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2008
-----------------------------------------------------
Last Update Date | 04/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 E MAIN ST
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61401-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-344-2595
-----------------------------------------------------
Fax | 309-344-2611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 209 E MAIN ST
-----------------------------------------------------
City | GALESBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61401-4716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-344-2595
-----------------------------------------------------
Fax | 309-344-2611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTAL HYGIENE COORDINATOR
-----------------------------------------------------
Name | MRS. KIM NORRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 309-344-2595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------