Healthcare Provider Details

I. General information

NPI: 1245541655
Provider Name (Legal Business Name): SCHOOL DISTRICT OF JANESVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 06/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 S FRANKLIN ST
JANESVILLE WI
53548-4779
US

IV. Provider business mailing address

527 S FRANKLIN ST
JANESVILLE WI
53548-4779
US

V. Phone/Fax

Practice location:
  • Phone: 608-743-5097
  • Fax: 608-743-5068
Mailing address:
  • Phone: 608-743-5097
  • Fax: 608-743-5068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1689811432
License Number StateWI

VIII. Authorized Official

Name: MR. MATHEW L HAEGER
Title or Position: MANAGER OF HEALTH AND SAFETY
Credential: RN
Phone: 608-743-5097