Provider Demographics
NPI:1649492133
Name:GRANT COMMUNITY SCHOOL DISTRICT 110
Entity type:Organization
Organization Name:GRANT COMMUNITY SCHOOL DISTRICT 110
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:STINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-397-2764
Mailing Address - Street 1:10110 OLD LINCOLN TRL
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2422
Mailing Address - Country:US
Mailing Address - Phone:618-397-2764
Mailing Address - Fax:618-398-5578
Practice Address - Street 1:10110 OLD LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2422
Practice Address - Country:US
Practice Address - Phone:618-397-2764
Practice Address - Fax:618-398-5578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
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