Provider Demographics
NPI:1245401371
Name:SCHOOL DISTRICT OF RANDOM LAKE
Entity type:Organization
Organization Name:SCHOOL DISTRICT OF RANDOM LAKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:O
Authorized Official - Last Name:MALMSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-994-4342
Mailing Address - Street 1:605 RANDOM LAKE RD
Mailing Address - Street 2:
Mailing Address - City:RANDOM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:53075-1646
Mailing Address - Country:US
Mailing Address - Phone:920-994-4342
Mailing Address - Fax:920-994-4820
Practice Address - Street 1:605 RANDOM LAKE RD
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075-1646
Practice Address - Country:US
Practice Address - Phone:920-994-4342
Practice Address - Fax:920-994-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44243900Medicaid