Provider Demographics
NPI:1861688152
Name:WILLOW LAKE SCHOOL 12 3
Entity Type:Organization
Organization Name:WILLOW LAKE SCHOOL 12 3
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:F
Authorized Official - Last Name:DENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-625-5945
Mailing Address - Street 1:PO BOX 170
Mailing Address - Street 2:400 GARFIELD ST
Mailing Address - City:WILLOW LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57278
Mailing Address - Country:US
Mailing Address - Phone:605-625-5945
Mailing Address - Fax:605-625-3103
Practice Address - Street 1:400 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:WILLOW LAKE
Practice Address - State:SD
Practice Address - Zip Code:57278
Practice Address - Country:US
Practice Address - Phone:605-625-5945
Practice Address - Fax:605-625-3103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5150480Medicaid