Provider Demographics
NPI:1063841401
Name:LAKE COUNTRY ACADEMY FOUNDATION INC
Entity Type:Organization
Organization Name:LAKE COUNTRY ACADEMY FOUNDATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-208-3020
Mailing Address - Street 1:4101 TECHNOLOGY PKWY
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-6049
Mailing Address - Country:US
Mailing Address - Phone:920-208-3020
Mailing Address - Fax:920-208-3022
Practice Address - Street 1:4101 TECHNOLOGY PKWY
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-6049
Practice Address - Country:US
Practice Address - Phone:920-208-3020
Practice Address - Fax:920-208-3022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)