Provider Demographics
NPI:1114044765
Name:CITY OF PELHAM BOARD OF EDUCATION
Entity Type:Organization
Organization Name:CITY OF PELHAM BOARD OF EDUCATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:VASSAR
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:386-884-9900
Mailing Address - Street 1:P O BOX 799
Mailing Address - Street 2:
Mailing Address - City:WHITE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32096-0799
Mailing Address - Country:US
Mailing Address - Phone:386-884-9900
Mailing Address - Fax:888-737-1652
Practice Address - Street 1:203 MATHEWSON AVE SW
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:GA
Practice Address - Zip Code:31779-2113
Practice Address - Country:US
Practice Address - Phone:229-294-8715
Practice Address - Fax:229-294-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000807111AMedicaid