Provider Demographics
NPI:1659500833
Name:BLACKHAWK PARK SCHOOL
Entity Type:Organization
Organization Name:BLACKHAWK PARK SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:J
Authorized Official - Middle Name:MAICHLE
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-720-4011
Mailing Address - Street 1:401 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2014
Mailing Address - Country:US
Mailing Address - Phone:815-720-4011
Mailing Address - Fax:815-720-4001
Practice Address - Street 1:330 15TH AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-5155
Practice Address - Country:US
Practice Address - Phone:815-972-7200
Practice Address - Fax:815-720-4001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINNEBAGO COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-08
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL771115034261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid