Provider Demographics
NPI:1386795623
Name:PELLA CSD
Entity type:Organization
Organization Name:PELLA CSD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:WITTMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-628-1111
Mailing Address - Street 1:210 E UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1970
Mailing Address - Country:US
Mailing Address - Phone:641-628-1111
Mailing Address - Fax:641-628-1116
Practice Address - Street 1:210 E UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1970
Practice Address - Country:US
Practice Address - Phone:641-628-1111
Practice Address - Fax:641-628-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0264994Medicaid