Basic Information
Provider Information | |||||||||
NPI: | 1073018016 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MT. DIABLO UNIFIED SCHOOL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUNRISE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1861 SILVERWOOD DR | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | CA | ||||||||
PostalCode: | 945191352 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9256870202 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1861 SILVERWOOD DR | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | CA | ||||||||
PostalCode: | 94519 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9256870202 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2018 | ||||||||
LastUpdateDate: | 07/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POZOS | ||||||||
AuthorizedOfficialFirstName: | JESSICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SPECIAL EDUCATION ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 9256828000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MT. DIABLO UNIFIED SCHOOL DISTRICT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251300000X |   |   | Y |   | Agencies | Local Education Agency (LEA) |   |
ID Information
ID | Type | State | Issuer | Description | SS0761754 | 05 | CA |   | MEDICAID |