Provider Demographics
NPI:1598951352
Name:BEREA INDEPENDENT SCHOOL
Entity Type:Organization
Organization Name:BEREA INDEPENDENT SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-986-8446
Mailing Address - Street 1:3 PIRATE PKWY
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1541
Mailing Address - Country:US
Mailing Address - Phone:859-986-1601
Mailing Address - Fax:859-986-1839
Practice Address - Street 1:3 PIRATE PKWY
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1541
Practice Address - Country:US
Practice Address - Phone:859-986-1601
Practice Address - Fax:859-986-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY21076021Medicaid