Provider Demographics
NPI:1598500357
Name:GOLD STAR PRIVATE ACADEMY INCORPORATED
Entity type:Organization
Organization Name:GOLD STAR PRIVATE ACADEMY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FUNDING SPECIALIST/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-601-5075
Mailing Address - Street 1:12008 NW STATE ROAD 20
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-3417
Mailing Address - Country:US
Mailing Address - Phone:850-601-5075
Mailing Address - Fax:
Practice Address - Street 1:12008 NW STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3417
Practice Address - Country:US
Practice Address - Phone:850-601-5075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)