Healthcare Provider Details

I. General information

NPI: 1720143944
Provider Name (Legal Business Name): INDEPENDENT SCHOOL DISTRICT 111
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HIGHWAY 25 SHLS NW
WATERTOWN MN
55388-9422
US

IV. Provider business mailing address

401 E 4TH ST
CHASKA MN
55318-2081
US

V. Phone/Fax

Practice location:
  • Phone: 952-368-8810
  • Fax: 952-227-5545
Mailing address:
  • Phone: 952-368-8810
  • Fax: 952-227-5545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KARSTEN ANDERSON
Title or Position: SUPERINTENDENT
Credential:
Phone: 952-955-0400