MEDICARE: DONGOLA SCHOOL UNIT DIST 66

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	261Q00000X	Clinic/Center		IL
2	261QS1000X	Student Health Clinic/Center		IL

General Provider Information

NPI Number	:	1154597698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONGOLA SCHOOL UNIT DIST 66

Provider Business Mailing Address
First Line	:	1000 HIGH STREET
Second Line	:
City	:	DONGOLA
State	:	IL
Zip	:	62926
Country	:	US
Telephone Number	:	618-827-3841
Fax Number	:	618-827-4641

Provider Business Practice Location Address
First Line	:	1000 HIGH STREET
Second Line	:
City	:	DONGOLA
State	:	IL
Zip	:	62926
Country	:	US
Telephone Number	:	618-827-3841
Fax Number	:	618-827-4641

Authorized Official
Title or Position	:	BOOKKEEPER
Name	:	MRS. DEBRA KAY LASTER
Credential	:
Telephone Number	:	618-827-3841

Provider Enumeration Date	:	05/05/2008
Last Update Date	:	05/05/2008

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Directions to “DONGOLA SCHOOL UNIT DIST 66 ” Practice Location

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