Provider Demographics
NPI:1134588031
Name:WHITE BEAR AREA SENIOR PROGAM ISD 624
Entity type:Organization
Organization Name:WHITE BEAR AREA SENIOR PROGAM ISD 624
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZMIERCZAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-623-3363
Mailing Address - Street 1:2484 COUNTY ROAD F E
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-7404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2484 COUNTY ROAD F E
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7404
Practice Address - Country:US
Practice Address - Phone:612-623-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA365023500Medicaid