Provider Demographics
NPI:1255473245
Name:FRUITVALE I S D
Entity Type:Organization
Organization Name:FRUITVALE I S D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-896-1191
Mailing Address - Street 1:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:FRUITVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75127-0077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:244 VZCR 1910
Practice Address - Street 2:
Practice Address - City:FRUITVALE
Practice Address - State:TX
Practice Address - Zip Code:75127
Practice Address - Country:US
Practice Address - Phone:903-896-1191
Practice Address - Fax:903-896-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065023602Medicaid