1104028679 NPI number — MINOOKA COMM CONS SCH DIST 201

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104028679 NPI number — MINOOKA COMM CONS SCH DIST 201

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINOOKA COMM CONS SCH DIST 201
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104028679
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 W COADY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINOOKA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60447-9118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 W COADY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINOOKA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60447-9118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-942-5780
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAND
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
815-942-5780

Provider Taxonomy Codes

  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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