MEDICARE: MARINE VILLAGE 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)

General Provider Information

NPI Number	:	1821852690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINE VILLAGE SCHOOL

Provider Business Mailing Address
First Line	:	550 PINE ST
Second Line	:
City	:	MARINE ON SAINT CROIX
State	:	MN
Zip	:	55047-4417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	550 PINE ST
Second Line	:
City	:	MARINE ON SAINT CROIX
State	:	MN
Zip	:	55047-4417
Country	:	US
Telephone Number	:	651-477-0380
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KIMBERLY KOKX
Credential	:
Telephone Number	:	651-477-0380

Provider Enumeration Date	:	02/12/2024
Last Update Date	:	02/12/2024

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Directions to “MARINE VILLAGE SCHOOL ” Practice Location

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