Provider Demographics
NPI:1558690628
Name:LOYOLA UNIVERSITY SCHOOL OF NURSING - SCHOOL-BASED HEALTH CENTER
Entity type:Organization
Organization Name:LOYOLA UNIVERSITY SCHOOL OF NURSING - SCHOOL-BASED HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROJECT DIRECTOR: LOYOLA UNIVERSITY
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:P
Authorized Official - Last Name:HACKBARTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN, FAAN
Authorized Official - Phone:708-216-3670
Mailing Address - Street 1:2160 SOUTH FIRST AVENUE
Mailing Address - Street 2:MAGUIRE - 105-2840
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-449-9522
Mailing Address - Fax:708-449-9525
Practice Address - Street 1:807 SOUTH FIRST AVENUE
Practice Address - Street 2:SCHOOL-BASED HEALTH CENTER AT PROVISO EAST HIGH SCHOOL
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-449-9522
Practice Address - Fax:708-449-9525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOYOLA UNIVERSITY HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health