Provider Demographics
NPI:1417136110
Name:SCHOOL DISTRICT OF SHELL LAKE
Entity Type:Organization
Organization Name:SCHOOL DISTRICT OF SHELL LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAUDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-468-7816
Mailing Address - Street 1:271 HIGHWAY 63 S
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-8893
Mailing Address - Country:US
Mailing Address - Phone:715-468-7816
Mailing Address - Fax:
Practice Address - Street 1:271 HIGHWAY 63 S
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871-8893
Practice Address - Country:US
Practice Address - Phone:715-468-7816
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44238600Medicaid