Healthcare Provider Details

I. General information

NPI: 1154528453
Provider Name (Legal Business Name): BLACK RIVER LOCAL SCHOOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257A CO RD 40
SULLIVAN OH
44880
US

IV. Provider business mailing address

257A CO RD 40
SULLIVAN OH
44880
US

V. Phone/Fax

Practice location:
  • Phone: 419-736-3300
  • Fax: 419-736-3308
Mailing address:
  • Phone: 419-736-3300
  • Fax: 419-736-3308

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: JANICE WYCKOFF
Title or Position: SUPERINTENDENT
Credential:
Phone: 419-736-3300