Provider Demographics
NPI:1235307471
Name:WEST CARROLL CUSD 314
Entity Type:Organization
Organization Name:WEST CARROLL CUSD 314
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-259-2735
Mailing Address - Street 1:801 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:IL
Mailing Address - Zip Code:61285-7500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 SOUTH ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:IL
Practice Address - Zip Code:61285-7500
Practice Address - Country:US
Practice Address - Phone:815-259-2735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
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