Provider Demographics
NPI:1598873176
Name:DIETERICH COMM UNIT 30
Entity Type:Organization
Organization Name:DIETERICH COMM UNIT 30
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-925-5249
Mailing Address - Street 1:205 S. PINE
Mailing Address - Street 2:PO BOX 107
Mailing Address - City:DIETERICH
Mailing Address - State:IL
Mailing Address - Zip Code:62424
Mailing Address - Country:US
Mailing Address - Phone:217-925-5249
Mailing Address - Fax:217-925-5447
Practice Address - Street 1:205 S. PINE
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424
Practice Address - Country:US
Practice Address - Phone:217-925-5249
Practice Address - Fax:217-925-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
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