Provider Demographics
NPI:1215135868
Name:BENNETT VALLEY UNION ELEM
Entity type:Organization
Organization Name:BENNETT VALLEY UNION ELEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:707-542-2201
Mailing Address - Street 1:2250 MESQUITE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-8310
Mailing Address - Country:US
Mailing Address - Phone:707-542-2201
Mailing Address - Fax:
Practice Address - Street 1:2250 MESQUITE DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-8310
Practice Address - Country:US
Practice Address - Phone:707-542-2201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASS4970623Medicaid