Provider Demographics
NPI:1427277060
Name:ROOSEVELT CITY DISTRICT BAINVILLE SCHOOL 64D
Entity type:Organization
Organization Name:ROOSEVELT CITY DISTRICT BAINVILLE SCHOOL 64D
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THALE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUDWICK
Authorized Official - Suffix:
Authorized Official - Credentials:BUSINESS MGR/BAINVIL
Authorized Official - Phone:406-769-2321
Mailing Address - Street 1:409 TUBMAN
Mailing Address - Street 2:
Mailing Address - City:BAINVILLE
Mailing Address - State:MT
Mailing Address - Zip Code:59212-0177
Mailing Address - Country:US
Mailing Address - Phone:406-769-2321
Mailing Address - Fax:406-769-2321
Practice Address - Street 1:409 TUBMAN
Practice Address - Street 2:
Practice Address - City:BAINVILLE
Practice Address - State:MT
Practice Address - Zip Code:59212-0177
Practice Address - Country:US
Practice Address - Phone:406-769-2321
Practice Address - Fax:406-769-2321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-08-20
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-12-03
Provider Licenses
StateLicense IDTaxonomies
MT251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0162825Medicaid