Provider Demographics
NPI:1659497196
Name:CARBONDALE HS DISTRAICT 165
Entity Type:Organization
Organization Name:CARBONDALE HS DISTRAICT 165
Other - Org Name:CARBONDALE COMMUNITY HIGH
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOSCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-4722
Mailing Address - Street 1:330 S GIANT CITY RD
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-5042
Mailing Address - Country:US
Mailing Address - Phone:618-457-4722
Mailing Address - Fax:618-457-3353
Practice Address - Street 1:330 S GIANT CITY RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-5042
Practice Address - Country:US
Practice Address - Phone:618-457-4722
Practice Address - Fax:618-457-3353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid