Provider Demographics
NPI:1679752018
Name:21ST CENTURY PREPARATORY SCHOOL
Entity Type:Organization
Organization Name:21ST CENTURY PREPARATORY SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MORELAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-598-0026
Mailing Address - Street 1:1220 MOUND AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-3350
Mailing Address - Country:US
Mailing Address - Phone:262-598-0026
Mailing Address - Fax:262-598-0031
Practice Address - Street 1:1220 MOUND AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-3350
Practice Address - Country:US
Practice Address - Phone:262-598-0026
Practice Address - Fax:262-598-0031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44222000Medicaid