Provider Demographics
NPI:1164696639
Name:SHAWNEE C U SCHOOL
Entity Type:Organization
Organization Name:SHAWNEE C U SCHOOL
Other - Org Name:SHAWNEE CUSD 84
Other - Org Type:Other Name
Authorized Official - Title/Position:UNIT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SEALS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-833-5709
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:3365 STATE HWY 3 N
Mailing Address - City:WOLF LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:62998-0128
Mailing Address - Country:US
Mailing Address - Phone:618-833-5709
Mailing Address - Fax:618-833-4171
Practice Address - Street 1:3365 STATE HWY 3 N
Practice Address - Street 2:3365 STATE HWY 3 N
Practice Address - City:WOLF LAKE
Practice Address - State:IL
Practice Address - Zip Code:62998-0128
Practice Address - Country:US
Practice Address - Phone:618-833-5709
Practice Address - Fax:618-833-4171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6299801Medicaid