MEDICARE: INDEPENDENT SCHOOL DISTRICT NO 22

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)	498923600	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	498923600	OTHER	MN	MA ID NUMBER

General Provider Information

NPI Number	:	1104996784
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT SCHOOL DISTRICT NO 22

Provider Business Mailing Address
First Line	:	702 LAKE AVE
Second Line	:	PO BOX 766
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3016
Country	:	US
Telephone Number	:	218-847-9271
Fax Number	:	218-847-9273

Provider Business Practice Location Address
First Line	:	702 LAKE AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3016
Country	:	US
Telephone Number	:	218-847-9271
Fax Number	:	218-847-9273

Authorized Official
Title or Position	:	SUPERINTENDENT OF SCHOOLS
Name	:	MR. DOUGLAS JAMES FROKE
Credential	:
Telephone Number	:	218-847-9271

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	07/15/2008

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