1205058658 NPI number — MOUNTAIN UNION ELEM. SCHOOL

Table of content: (NPI 1205058658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205058658 NPI number — MOUNTAIN UNION ELEM. SCHOOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN UNION ELEM. SCHOOL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205058658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30365 HIGHWAY 299
Provider Second Line Business Mailing Address:
PO BOX 368
Provider Business Mailing Address City Name:
MONTGOMERY CREEK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-337-6214
Provider Business Mailing Address Fax Number:
530-337-6215

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30365 HIGHWAY 299
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTGOMERY CREEK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-337-6214
Provider Business Practice Location Address Fax Number:
530-337-6215
Provider Enumeration Date:
05/03/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRADY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
SUPERINTENDENT
Authorized Official Telephone Number:
530-337-6214

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SS4573700 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".