Provider Demographics
NPI:1669520326
Name:EVERGREEN ELEMENTARY SCHOOL DISTRICT
Entity type:Organization
Organization Name:EVERGREEN ELEMENTARY SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:CLEAR ADMINISTRATIVE
Authorized Official - Phone:408-270-6814
Mailing Address - Street 1:3188 QUIMBY ROAD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95148-3022
Mailing Address - Country:US
Mailing Address - Phone:408-270-6800
Mailing Address - Fax:408-274-3894
Practice Address - Street 1:3188 QUIMBY ROAD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95148-3022
Practice Address - Country:US
Practice Address - Phone:408-270-6800
Practice Address - Fax:408-274-3894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X
CA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43-69435OtherMEDI-CAL