Provider Demographics
NPI:1184110447
Name:BUENA VISTA ISD
Entity type:Organization
Organization Name:BUENA VISTA ISD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAVIDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-536-2236
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:TX
Mailing Address - Zip Code:79743-0310
Mailing Address - Country:US
Mailing Address - Phone:432-536-2336
Mailing Address - Fax:432-536-2469
Practice Address - Street 1:404 HIGHWAY 11 W
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:TX
Practice Address - Zip Code:79743
Practice Address - Country:US
Practice Address - Phone:432-536-2336
Practice Address - Fax:432-536-2469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid