Provider Demographics
NPI:1346429958
Name:MONDOVI SCHOOL DISTRICT
Entity type:Organization
Organization Name:MONDOVI SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:GULLICKSRUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-926-3684
Mailing Address - Street 1:337 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1155
Mailing Address - Country:US
Mailing Address - Phone:715-926-3684
Mailing Address - Fax:715-926-3617
Practice Address - Street 1:337 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1155
Practice Address - Country:US
Practice Address - Phone:715-926-3684
Practice Address - Fax:715-926-3617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44233200Medicaid