Provider Demographics
NPI:1841344017
Name:INDIAN LAKE CSD
Entity type:Organization
Organization Name:INDIAN LAKE CSD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-648-5024
Mailing Address - Street 1:28 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12842-1500
Mailing Address - Country:US
Mailing Address - Phone:518-648-5024
Mailing Address - Fax:518-648-6346
Practice Address - Street 1:28 W MAIN ST
Practice Address - Street 2:
Practice Address - City:INDIAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:12842-1500
Practice Address - Country:US
Practice Address - Phone:518-648-5024
Practice Address - Fax:518-648-6346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01382301Medicaid