Provider Demographics
NPI:1598804031
Name:PONTIAC-WM HOLLIDAY SD 105
Entity Type:Organization
Organization Name:PONTIAC-WM HOLLIDAY SD 105
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-233-2320
Mailing Address - Street 1:400 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2802
Mailing Address - Country:US
Mailing Address - Phone:618-233-2320
Mailing Address - Fax:618-233-0918
Practice Address - Street 1:400 ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2802
Practice Address - Country:US
Practice Address - Phone:618-233-2320
Practice Address - Fax:618-233-0918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
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