Healthcare Provider Details

I. General information

NPI: 1639358070
Provider Name (Legal Business Name): SCHOOL DISTRICT OF EDGAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E BIRCH ST
EDGAR WI
54426-9086
US

IV. Provider business mailing address

203 E BIRCH ST
EDGAR WI
54426-9086
US

V. Phone/Fax

Practice location:
  • Phone: 715-352-2351
  • Fax:
Mailing address:
  • Phone: 715-352-2351
  • Fax:

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: MR. MARK LACKE
Title or Position: ADMINISTRATOR
Credential:
Phone: 715-352-2351