Provider Demographics
NPI:1053458547
Name:COUNTY OF CANYON SCHOOL DISTRICT CLASS B 136J
Entity Type:Organization
Organization Name:COUNTY OF CANYON SCHOOL DISTRICT CLASS B 136J
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 1:176 E CALDERWOOD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9097
Mailing Address - Country:US
Mailing Address - Phone:208-922-3093
Mailing Address - Fax:208-922-9351
Practice Address - Street 1:520 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MELBA
Practice Address - State:ID
Practice Address - Zip Code:83641
Practice Address - Country:US
Practice Address - Phone:208-495-1141
Practice Address - Fax:208-495-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806406400Medicaid