Provider Demographics
NPI:1578633269
Name:ST. JOSEPH COUNTY ISD
Entity Type:Organization
Organization Name:ST. JOSEPH COUNTY ISD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-467-5418
Mailing Address - Street 1:62445 SHIMMEL RD
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032-9527
Mailing Address - Country:US
Mailing Address - Phone:269-467-5400
Mailing Address - Fax:269-467-4309
Practice Address - Street 1:62445 SHIMMEL RD
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032-9527
Practice Address - Country:US
Practice Address - Phone:269-467-5400
Practice Address - Fax:269-467-4309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2989210Medicaid