Provider Demographics
NPI:1346388287
Name:MESA UNIFIED SCHOOL DISTRICT NO. 4
Entity Type:Organization
Organization Name:MESA UNIFIED SCHOOL DISTRICT NO. 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR MEDICAID MONITORING
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGACRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-472-0685
Mailing Address - Street 1:1025 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3302
Mailing Address - Country:US
Mailing Address - Phone:480-472-0685
Mailing Address - Fax:480-472-0705
Practice Address - Street 1:1025 N COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3302
Practice Address - Country:US
Practice Address - Phone:480-472-0685
Practice Address - Fax:480-472-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ568991Medicaid