Provider Demographics
NPI:1720203599
Name:ELKHART LAKE-GLENBEULAH SCHOOL DISTRICT
Entity Type:Organization
Organization Name:ELKHART LAKE-GLENBEULAH SCHOOL DISTRICT
Other - Org Name:JT SCHOOL DIST NO 1 ELKHART LAKE TWNS RHINE RUSSELL & HERMAN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR OF STUDENT SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:BARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-876-3307
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:ELKHART LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53020-0518
Mailing Address - Country:US
Mailing Address - Phone:920-876-3307
Mailing Address - Fax:920-876-3105
Practice Address - Street 1:201 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:ELKHART LAKE
Practice Address - State:WI
Practice Address - Zip Code:53020-1966
Practice Address - Country:US
Practice Address - Phone:920-876-3307
Practice Address - Fax:920-876-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44219500Medicaid