1770649915 NPI number — IND SCHOOL DIST 624

Table of content: (NPI 1770649915)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770649915 NPI number — IND SCHOOL DIST 624

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IND SCHOOL DIST 624
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770649915
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4855 BLOOM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE BEAR LAKE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55110-2731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-407-7568
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4855 BLOOM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE BEAR LAKE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55110-2731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-407-7568
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
POPE
Authorized Official First Name:
ELSA
Authorized Official Middle Name:
MAE
Authorized Official Title or Position:
DIR OF HR
Authorized Official Telephone Number:
651-407-7550

Provider Taxonomy Codes

  • Taxonomy code: 251300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 530678700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com