Provider Demographics
NPI:1245397603
Name:ISD 763 MEDFORD PUBLIC SCHOOL
Entity Type:Organization
Organization Name:ISD 763 MEDFORD PUBLIC SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL EDUCATION COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-451-5250
Mailing Address - Street 1:750 2ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MN
Mailing Address - Zip Code:55049-9586
Mailing Address - Country:US
Mailing Address - Phone:507-451-5250
Mailing Address - Fax:507-451-6474
Practice Address - Street 1:750 2ND AVE SE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MN
Practice Address - Zip Code:55049-9586
Practice Address - Country:US
Practice Address - Phone:507-451-5250
Practice Address - Fax:507-451-6474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN901405500Medicaid