Provider Demographics
NPI:1417000670
Name:LISBON GRADE SCHOOL #90
Entity Type:Organization
Organization Name:LISBON GRADE SCHOOL #90
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-736-6324
Mailing Address - Street 1:127 S CANAL ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:IL
Mailing Address - Zip Code:60541-9776
Mailing Address - Country:US
Mailing Address - Phone:815-736-6324
Mailing Address - Fax:815-736-6326
Practice Address - Street 1:127 S CANAL ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:IL
Practice Address - Zip Code:60541-9776
Practice Address - Country:US
Practice Address - Phone:815-736-6324
Practice Address - Fax:815-736-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid