Provider Demographics
NPI:1619192069
Name:IND SCHOOL DIST NO 561 PENNINGTON & MARSHALL COS
Entity Type:Organization
Organization Name:IND SCHOOL DIST NO 561 PENNINGTON & MARSHALL COS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-378-4133
Mailing Address - Street 1:PO BOX 195
Mailing Address - Street 2:OSMUND AVENUE
Mailing Address - City:GOODRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:56725
Mailing Address - Country:US
Mailing Address - Phone:218-378-4134
Mailing Address - Fax:
Practice Address - Street 1:OSMUND AVENUE
Practice Address - Street 2:
Practice Address - City:GOODRIDGE
Practice Address - State:MN
Practice Address - Zip Code:56725
Practice Address - Country:US
Practice Address - Phone:218-378-4134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN440055100Medicare UPIN