MEDICARE: SPECTRUM HIGH SCHOOL

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)		MN

General Provider Information

NPI Number	:	1457624801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECTRUM HIGH SCHOOL

Provider Business Mailing Address
First Line	:	17796 INDUSTRIAL CIR NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330-4754
Country	:	US
Telephone Number	:	763-663-1380
Fax Number	:

Provider Business Practice Location Address
First Line	:	17796 INDUSTRIAL CIR NW
Second Line	:
City	:	ELK RIVER
State	:	MN
Zip	:	55330-4754
Country	:	US
Telephone Number	:	763-663-1380
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL EDUCATION TEACHER
Name	:	KARIN NESS
Credential	:
Telephone Number	:	763-633-1380

Provider Enumeration Date	:	02/15/2012
Last Update Date	:	02/15/2012

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