Provider Demographics
NPI:1689790644
Name:CITY OF SANTA ROSA ELEMENTARY
Entity Type:Organization
Organization Name:CITY OF SANTA ROSA ELEMENTARY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-528-5321
Mailing Address - Street 1:217 RIDGEWAY AVE
Mailing Address - Street 2:OFFICE OF SPECIAL SERVICES
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4320
Mailing Address - Country:US
Mailing Address - Phone:707-528-5321
Mailing Address - Fax:707-547-5889
Practice Address - Street 1:217 RIDGEWAY AVE
Practice Address - Street 2:OFFICE OF SPECIAL SERVICES
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4320
Practice Address - Country:US
Practice Address - Phone:707-528-5321
Practice Address - Fax:707-547-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASS4970912Medicaid