Provider Demographics
NPI:1053450429
Name:COUNTY OF CANYON CANYON CO SCHOOL DIST 132
Entity Type:Organization
Organization Name:COUNTY OF CANYON CANYON CO SCHOOL DIST 132
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SYSTEMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:LEVESQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-922-3093
Mailing Address - Street 1:104 E FAIRVIEW AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1733
Mailing Address - Country:US
Mailing Address - Phone:208-922-3093
Mailing Address - Fax:208-922-9351
Practice Address - Street 1:1101 CLEVELAND BLVD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-3855
Practice Address - Country:US
Practice Address - Phone:208-455-3300
Practice Address - Fax:208-455-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID804005800Medicaid