Provider Demographics
NPI:1922133412
Name:OFALLON CCSD 90
Entity Type:Organization
Organization Name:OFALLON CCSD 90
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-632-3666
Mailing Address - Street 1:707 N SMILEY ST
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1353
Mailing Address - Country:US
Mailing Address - Phone:618-632-3666
Mailing Address - Fax:618-632-7864
Practice Address - Street 1:707 N SMILEY ST
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1353
Practice Address - Country:US
Practice Address - Phone:618-632-3666
Practice Address - Fax:618-632-7864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
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