Provider Demographics
NPI:1790964674
Name:SCHOOL DISTRICT OF KETTLE MORAINE
Entity Type:Organization
Organization Name:SCHOOL DISTRICT OF KETTLE MORAINE
Other - Org Name:KETTLE MORAINE SCHOOL DISTRICT
Other - Org Type:Other Name
Authorized Official - Title/Position:ASST SUPT OF PUPIL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:262-968-6300
Mailing Address - Street 1:563 A J ALLEN CIR
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9649
Mailing Address - Country:US
Mailing Address - Phone:262-968-6300
Mailing Address - Fax:262-968-6390
Practice Address - Street 1:563 A J ALLEN CIR
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9649
Practice Address - Country:US
Practice Address - Phone:262-968-6300
Practice Address - Fax:262-968-6390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44200200Medicaid