MEDICARE: BROOKWOOD SCHOOL JT SCHOOL DIST 2

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	:	1508315425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKWOOD SCHOOL JT SCHOOL DIST 2

Provider Business Mailing Address
First Line	:	1020 HUNTERS RIDGE DR
Second Line	:	PO BOX 250
City	:	GENOA CITY
State	:	WI
Zip	:	53128-2508
Country	:	US
Telephone Number	:	262-279-1051
Fax Number	:	262-279-1052

Provider Business Practice Location Address
First Line	:	1020 HUNTERS RIDGE DR
Second Line	:
City	:	GENOA CITY
State	:	WI
Zip	:	53128-2508
Country	:	US
Telephone Number	:	262-279-1051
Fax Number	:	262-279-1052

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MARY DEYOUNG
Credential	:
Telephone Number	:	262-279-1053

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/04/2016

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