Provider Demographics
NPI:1144411612
Name:GREEN LAKE SCHOOL DISTRICT
Entity Type:Organization
Organization Name:GREEN LAKE SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-294-6411
Mailing Address - Street 1:612 MILL ST
Mailing Address - Street 2:
Mailing Address - City:GREEN LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 MILL ST
Practice Address - Street 2:
Practice Address - City:GREEN LAKE
Practice Address - State:WI
Practice Address - Zip Code:54941
Practice Address - Country:US
Practice Address - Phone:920-294-6411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44226900Medicaid