Provider Demographics
NPI:1649830944
Name:DEMOCRACY PREP AGASSI CAMPUS
Entity type:Organization
Organization Name:DEMOCRACY PREP AGASSI CAMPUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SPECIAL EDUCATION
Authorized Official - Prefix:
Authorized Official - First Name:ELLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-501-0187
Mailing Address - Street 1:1201 W LAKE MEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-2411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1201 W LAKE MEAD BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2411
Practice Address - Country:US
Practice Address - Phone:702-316-2410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)