=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417000670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISBON GRADE SCHOOL #90
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127 S CANAL ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60541-9776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-736-6324
-----------------------------------------------------
Fax | 815-736-6326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 S CANAL ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60541-9776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-736-6324
-----------------------------------------------------
Fax | 815-736-6326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | MR. MICHAEL RUSTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 815-736-6324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------