Healthcare Provider Details

I. General information

NPI: 1245397603
Provider Name (Legal Business Name): ISD 763 MEDFORD PUBLIC SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 2ND AVE SE
MEDFORD MN
55049-9586
US

IV. Provider business mailing address

750 2ND AVE SE
MEDFORD MN
55049-9586
US

V. Phone/Fax

Practice location:
  • Phone: 507-451-5250
  • Fax: 507-451-6474
Mailing address:
  • Phone: 507-451-5250
  • Fax: 507-451-6474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateMN

VIII. Authorized Official

Name: GARY BRAUN
Title or Position: SPECIAL EDUCATION COORDINATOR
Credential:
Phone: 507-451-5250