Provider Demographics
NPI:1598787665
Name:POTTAWATOMIE WABAUNSEE INFANT TODDLER
Entity Type:Organization
Organization Name:POTTAWATOMIE WABAUNSEE INFANT TODDLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BILDERBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-456-7366
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:KS
Mailing Address - Zip Code:66743-0189
Mailing Address - Country:US
Mailing Address - Phone:620-724-6281
Mailing Address - Fax:620-724-7141
Practice Address - Street 1:510 E HWY 24
Practice Address - Street 2:
Practice Address - City:WAMEGO
Practice Address - State:KS
Practice Address - Zip Code:66547
Practice Address - Country:US
Practice Address - Phone:785-456-7366
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100212080BMedicaid