Provider Demographics
NPI:1225200850
Name:DESOTO CCSD 86
Entity type:Organization
Organization Name:DESOTO CCSD 86
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-867-2317
Mailing Address - Street 1:311 HURST RD
Mailing Address - Street 2:
Mailing Address - City:DE SOTO
Mailing Address - State:IL
Mailing Address - Zip Code:62924-1228
Mailing Address - Country:US
Mailing Address - Phone:618-867-2317
Mailing Address - Fax:618-867-3233
Practice Address - Street 1:311 HURST RD
Practice Address - Street 2:
Practice Address - City:DE SOTO
Practice Address - State:IL
Practice Address - Zip Code:62924-1228
Practice Address - Country:US
Practice Address - Phone:618-867-2317
Practice Address - Fax:618-867-3233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6292401Medicaid