Provider Demographics
NPI:1306357710
Name:MARINE AREA COMMUNITY SCHOOL
Entity Type:Organization
Organization Name:MARINE AREA COMMUNITY SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SCHOOL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-409-3122
Mailing Address - Street 1:14189 OSTLUND TRL N
Mailing Address - Street 2:
Mailing Address - City:MARINE ON SAINT CROIX
Mailing Address - State:MN
Mailing Address - Zip Code:55047-4419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14189 OSTLUND TRL N
Practice Address - Street 2:
Practice Address - City:MARINE ON SAINT CROIX
Practice Address - State:MN
Practice Address - Zip Code:55047-4419
Practice Address - Country:US
Practice Address - Phone:651-409-3122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN=========Medicaid