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?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44214800Medicaid