Provider Demographics
NPI:1710166277
Name:PLYMOUTH JOINT SCHOOL DISTRICT
Entity Type:Organization
Organization Name:PLYMOUTH JOINT SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUPIL SERVICES DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-892-5022
Mailing Address - Street 1:125 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-2566
Mailing Address - Country:US
Mailing Address - Phone:920-892-5022
Mailing Address - Fax:920-892-5078
Practice Address - Street 1:125 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-2566
Practice Address - Country:US
Practice Address - Phone:920-892-5022
Practice Address - Fax:920-892-5078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44218400Medicaid