MEDICARE: PROVISO TOWNSHIP HIGH SCHOOL DISTRICT 209

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1124270103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVISO TOWNSHIP HIGH SCHOOL DISTRICT 209

Provider Business Mailing Address
First Line	:	8601 ROOSEVELT RD
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2532
Country	:	US
Telephone Number	:	708-338-5950
Fax Number	:

Provider Business Practice Location Address
First Line	:	8601 ROOSEVELT RD
Second Line	:
City	:	FOREST PARK
State	:	IL
Zip	:	60130-2532
Country	:	US
Telephone Number	:	708-338-5950
Fax Number	:

Authorized Official
Title or Position	:	ASST SUP FOR FINANCE & OPERATIONS
Name	:	DR. NIKITA JOHNSON
Credential	:
Telephone Number	:	708-338-5929

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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