Provider Demographics
NPI:1043488554
Name:CRESTON COMM SCHOOL
Entity Type:Organization
Organization Name:CRESTON COMM SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-382-3920
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:CRESTON
Mailing Address - State:IL
Mailing Address - Zip Code:60113-0037
Mailing Address - Country:US
Mailing Address - Phone:815-382-3920
Mailing Address - Fax:
Practice Address - Street 1:202 W SOUTH STREET
Practice Address - Street 2:
Practice Address - City:ROCHELLE
Practice Address - State:IL
Practice Address - Zip Code:61068
Practice Address - Country:US
Practice Address - Phone:815-382-3920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid