Provider Demographics
NPI:1114381969
Name:SWEETWATER UNION HIGH SCHOOL DISTRICT
Entity Type:Organization
Organization Name:SWEETWATER UNION HIGH SCHOOL DISTRICT
Other - Org Name:SWEETWATER OUTPATIENT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OF EDUCATIONAL EQUITY
Authorized Official - Prefix:DR
Authorized Official - First Name:R. VERNON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:ED D
Authorized Official - Phone:619-407-4933
Mailing Address - Street 1:1130 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2812
Mailing Address - Country:US
Mailing Address - Phone:619-407-4920
Mailing Address - Fax:
Practice Address - Street 1:1051 PICADOR BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3548
Practice Address - Country:US
Practice Address - Phone:619-662-8372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SWEETWATER UNION HIGH SCHOOL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-07
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251300000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)