Provider Demographics
NPI:1235256520
Name:KANKAKEE SCHOOL DISTRICT 111 SCHOOL-BASED HEALTH CENTER
Entity Type:Organization
Organization Name:KANKAKEE SCHOOL DISTRICT 111 SCHOOL-BASED HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-0772
Mailing Address - Street 1:2250 E CRESTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2803
Mailing Address - Country:US
Mailing Address - Phone:815-933-0772
Mailing Address - Fax:815-933-6730
Practice Address - Street 1:2250 E CRESTWOOD ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2803
Practice Address - Country:US
Practice Address - Phone:815-933-0772
Practice Address - Fax:815-933-6730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X, 261QS1000X, 261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336004784004Medicaid
IL=========003Medicaid
IL=========005Medicaid