=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699891721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENNOYER DISTRICT 79
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5200 N CUMBERLAND AVE
-----------------------------------------------------
City | NORRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60706-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-456-9094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5200 N CUMBERLAND AVE
-----------------------------------------------------
City | NORRIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60706-1499
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-456-9094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | DR. THOMAS ZAFIRATOS
-----------------------------------------------------
Credential | ED.D
-----------------------------------------------------
Telephone | 708-456-9094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------