Provider Demographics
NPI:1821165101
Name:ST. JOHNS SCHOOL DISTRICT
Entity Type:Organization
Organization Name:ST. JOHNS SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE SECRETARY-MEDICAID
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-819-7149
Mailing Address - Street 1:40 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3633
Mailing Address - Country:US
Mailing Address - Phone:904-819-7500
Mailing Address - Fax:904-819-7145
Practice Address - Street 1:1 CHRISTOPHER ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4056
Practice Address - Country:US
Practice Address - Phone:904-819-7149
Practice Address - Fax:904-819-7145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)