MEDICARE: CLEARBROOK-GONVICK ISD #2311

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)

General Provider Information

NPI Number	:	1417047820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLEARBROOK-GONVICK ISD #2311

Provider Business Mailing Address
First Line	:	16770 CLEARWATER LAKE RD
Second Line	:
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-4223
Country	:	US
Telephone Number	:	208-776-3112
Fax Number	:	218-776-3117

Provider Business Practice Location Address
First Line	:	16770 CLEARWATER LAKE RD
Second Line	:
City	:	CLEARBROOK
State	:	MN
Zip	:	56634-4223
Country	:	US
Telephone Number	:	208-776-3112
Fax Number	:	218-776-3117

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MS. DIANE LEHSE
Credential	:
Telephone Number	:	218-776-3112

Provider Enumeration Date	:	10/14/2006
Last Update Date	:	08/22/2020

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