=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659438695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLSBORO CENTRAL SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 02/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 SCHOOL LANE
-----------------------------------------------------
City | WILLSBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-963-4456
-----------------------------------------------------
Fax | 518-963-7577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 SCHOOL LANE PO BOX 180
-----------------------------------------------------
City | WILLSBORO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-963-4456
-----------------------------------------------------
Fax | 518-963-7577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | STEPHEN BROADWELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 518-963-4456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------