Provider Demographics
NPI:1972513166
Name:INDEPENDENT SCHOOL DISTRICT 484
Entity type:Organization
Organization Name:INDEPENDENT SCHOOL DISTRICT 484
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:V
Authorized Official - Last Name:ATHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-468-6458
Mailing Address - Street 1:112 KAMNIC ST
Mailing Address - Street 2:
Mailing Address - City:PIERZ
Mailing Address - State:MN
Mailing Address - Zip Code:56364-4000
Mailing Address - Country:US
Mailing Address - Phone:320-468-6458
Mailing Address - Fax:320-468-6408
Practice Address - Street 1:112 KAMNIC ST
Practice Address - Street 2:
Practice Address - City:PIERZ
Practice Address - State:MN
Practice Address - Zip Code:56364-4000
Practice Address - Country:US
Practice Address - Phone:320-468-6458
Practice Address - Fax:320-468-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN897952900Medicaid