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General NPI Number Information
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NPI Number | 1659500833
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Entity Type | Organization
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Legal Business Name | BLACKHAWK PARK SCHOOL
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Dates
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Enumeration Date | 07/08/2009
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Last Update Date | 12/12/2012
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Provider Practice Location Address
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Address Line | 330 15TH AVE
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City | ROCKFORD
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State | IL
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Zip | 61104-5155
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Country | US
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Telephone | 815-972-7200
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Fax | 815-720-4001
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Provider Business Mailing Address
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Address Line | 401 DIVISION ST
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City | ROCKFORD
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State | IL
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Zip | 61104-2014
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Country | US
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Telephone | 815-720-4011
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Fax | 815-720-4001
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. J MAICHLE BACON
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Credential |
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Telephone | 815-720-4011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number | 771115034
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License Number State | IL
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