Provider Demographics
NPI:1134486061
Name:BROCK INDEPENDENT SCHOOL DISTRICT
Entity Type:Organization
Organization Name:BROCK INDEPENDENT SCHOOL DISTRICT
Other - Org Name:BROCK ISD
Other - Org Type:Other Name
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-594-7642
Mailing Address - Street 1:410 EAGLE SPIRIT LN
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-5606
Mailing Address - Country:US
Mailing Address - Phone:817-594-7642
Mailing Address - Fax:
Practice Address - Street 1:410 EAGLE SPIRIT LN
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-5606
Practice Address - Country:US
Practice Address - Phone:817-594-7642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-17
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX064903002Medicaid