Provider Demographics
NPI: | 1619140233 |
---|---|
Name: | SCHOOL DISTRICT OF INDEPENDENCE |
Entity Type: | Organization |
Organization Name: | SCHOOL DISTRICT OF INDEPENDENCE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | DISTRICT ADMINISTRATOR |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | DAVE |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LAEHN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 715-985-3172 |
Mailing Address - Street 1: | 23786 INDEE BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | INDEPENDENCE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54747-9095 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 715-985-3172 |
Mailing Address - Fax: | 715-985-2303 |
Practice Address - Street 1: | 23786 INDEE BLVD |
Practice Address - Street 2: | |
Practice Address - City: | INDEPENDENCE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54747-9095 |
Practice Address - Country: | US |
Practice Address - Phone: | 715-985-3172 |
Practice Address - Fax: | 715-985-2303 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-04-03 |
Last Update Date: | 2008-04-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251300000X | Agencies | Local Education Agency (LEA) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 44214800 | Medicaid |