Provider Demographics
NPI:1922208099
Name:PAINTED DESERT DEMONSTRATION PROJECT
Entity Type:Organization
Organization Name:PAINTED DESERT DEMONSTRATION PROJECT
Other - Org Name:STAR SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:602-412-3533
Mailing Address - Street 1:145 LEUPP RD
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-8501
Mailing Address - Country:US
Mailing Address - Phone:602-412-3533
Mailing Address - Fax:928-225-2179
Practice Address - Street 1:145 LEUPP RD
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-8501
Practice Address - Country:US
Practice Address - Phone:602-412-3533
Practice Address - Fax:928-225-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ908600OtherAHCCCS