MEDICARE: SHAWNEE CUSD 84

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	261QS1000X	Student Health Clinic/Center		IL

General Provider Information

NPI Number	:	1669599098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAWNEE CUSD 84

Provider Business Mailing Address
First Line	:	PO BOX 128
Second Line	:	3365 STATE HWY. 3 N
City	:	WOLF LAKE
State	:	IL
Zip	:	62998-0128
Country	:	US
Telephone Number	:	618-833-5709
Fax Number	:	618-833-4171

Provider Business Practice Location Address
First Line	:	3365 IL HWY 3N
Second Line	:
City	:	WOLF LAKE
State	:	IL
Zip	:	62998-0128
Country	:	US
Telephone Number	:	618-833-5709
Fax Number	:	618-833-4171

Authorized Official
Title or Position	:	UNIT SECRETARY
Name	:	DEBRA L SEALS
Credential	:
Telephone Number	:	61868335709

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	08/22/2020

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