Provider Demographics
NPI:1093015265
Name:SPIRIT LAKE HEAD START
Entity Type:Organization
Organization Name:SPIRIT LAKE HEAD START
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:LANE
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:701-766-1370
Mailing Address - Street 1:816 3RD AVE NORTH
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335
Mailing Address - Country:US
Mailing Address - Phone:701-766-4070
Mailing Address - Fax:701-766-1357
Practice Address - Street 1:816 3RD AVE NORTH
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-766-4070
Practice Address - Fax:701-766-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR34550251J00000X
261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service