Provider Demographics
NPI:1881724565
Name:SPRING GARDEN COMMUNITY CONSOLIDATED SCHOOL DISTRICT #178
Entity type:Organization
Organization Name:SPRING GARDEN COMMUNITY CONSOLIDATED SCHOOL DISTRICT #178
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:STRAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-244-8070
Mailing Address - Street 1:14975 E BAKERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-244-8070
Mailing Address - Fax:618-244-8071
Practice Address - Street 1:14975 E BAKERVILLE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-8070
Practice Address - Fax:618-244-8071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent HealthGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid