Provider Demographics
NPI:1235277765
Name:FAIRFIELD SCHOOL DISTRICT 12
Entity type:Organization
Organization Name:FAIRFIELD SCHOOL DISTRICT 12
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-842-6501
Mailing Address - Street 1:806 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2458
Mailing Address - Country:US
Mailing Address - Phone:618-842-6501
Mailing Address - Fax:618-842-2932
Practice Address - Street 1:806 N 1ST ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2458
Practice Address - Country:US
Practice Address - Phone:618-842-6501
Practice Address - Fax:618-842-2932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
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