=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508982703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIANT CITY CC SCHOOL DIST 130
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1062 BOSKYDELL RD
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62902-7743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-457-5391
-----------------------------------------------------
Fax | 618-549-5060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1062 BOSKYDELL RD
-----------------------------------------------------
City | CARBONDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62902-7743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-457-5391
-----------------------------------------------------
Fax | 618-549-5060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | MR. WILLIAM R ROGERS
-----------------------------------------------------
Credential | M.S. EDUCATION ADMIN
-----------------------------------------------------
Telephone | 618-457-5391
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QS1000X
-----------------------------------------------------
Taxonomy Name | Student Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------