MEDICARE: EL COLEGIO VIA EDVISIONS COOPERATIVE

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)	450625	MN

General Provider Information

NPI Number	:	1770858813
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL COLEGIO VIA EDVISIONS COOPERATIVE

Provider Business Mailing Address
First Line	:	4137 BLOOMINGTON AVENUE SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3332
Country	:	US
Telephone Number	:	612-728-5728
Fax Number	:

Provider Business Practice Location Address
First Line	:	4137 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3332
Country	:	US
Telephone Number	:	612-728-5728
Fax Number	:

Authorized Official
Title or Position	:	SPECIAL EDUCATION TEACHER
Name	:	DANIEL J ITTNER
Credential	:
Telephone Number	:	612-728-5728

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	03/21/2012

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