Provider Demographics
NPI:1255487351
Name:SIERRA VISTA PUBLIC SCHOOL DISTRICT #68
Entity Type:Organization
Organization Name:SIERRA VISTA PUBLIC SCHOOL DISTRICT #68
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MIPS COORDINATION
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-515-2768
Mailing Address - Street 1:3555 E FRY BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635
Mailing Address - Country:US
Mailing Address - Phone:520-515-2768
Mailing Address - Fax:520-515-2726
Practice Address - Street 1:3555 E FRY BOULEVARD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635
Practice Address - Country:US
Practice Address - Phone:520-515-2768
Practice Address - Fax:520-515-2726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ579633Medicaid