Healthcare Provider Details

I. General information

NPI: 1144411612
Provider Name (Legal Business Name): GREEN LAKE SCHOOL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 MILL ST
GREEN LAKE WI
54941
US

IV. Provider business mailing address

612 MILL ST
GREEN LAKE WI
54941
US

V. Phone/Fax

Practice location:
  • Phone: 920-294-6411
  • Fax:
Mailing address:
  • Phone:
  • 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. KEN BATES
Title or Position: DISTRICT ADMINISTRATOR
Credential:
Phone: 920-294-6411