Provider Demographics
NPI:1255645149
Name:PINE GROVE LEADERSHIP ACADEMY
Entity type:Organization
Organization Name:PINE GROVE LEADERSHIP ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:AMILIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-384-7598
Mailing Address - Street 1:63842 OJIBWE RD
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-3342
Mailing Address - Country:US
Mailing Address - Phone:320-384-7598
Mailing Address - Fax:320-384-7485
Practice Address - Street 1:63842 OJIBWE RD
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-3342
Practice Address - Country:US
Practice Address - Phone:320-384-7598
Practice Address - Fax:320-384-7485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-03
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)