=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609972165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLESTON COMMUNITY UNIT SCHOOL DISTRICT #1
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 W POLK AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61920-2557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-639-1000
-----------------------------------------------------
Fax | 217-639-1005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 W POLK AVE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61920-2557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-639-1000
-----------------------------------------------------
Fax | 217-639-1005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | DR. GARY NIEHAUS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-639-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------