Provider Demographics
NPI:1669522231
Name:ROSWELL INDEPENDENT SCHOOL DISTRICT
Entity type:Organization
Organization Name:ROSWELL INDEPENDENT SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID PROGRAM SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-627-2543
Mailing Address - Street 1:300 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4636
Mailing Address - Country:US
Mailing Address - Phone:505-627-2543
Mailing Address - Fax:505-627-2544
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-627-2543
Practice Address - Fax:505-627-2544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ7697Medicaid