Provider Demographics
NPI:1285787598
Name:GRACE JT SCHOOL DISTRICT
Entity type:Organization
Organization Name:GRACE JT SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:208-425-9161
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:704 SHOUT HWY 30
Mailing Address - City:GRACE
Mailing Address - State:ID
Mailing Address - Zip Code:83241
Mailing Address - Country:US
Mailing Address - Phone:208-425-3731
Mailing Address - Fax:208-425-3063
Practice Address - Street 1:704 SOUTH HWY 30
Practice Address - Street 2:
Practice Address - City:GRACE
Practice Address - State:ID
Practice Address - Zip Code:83241
Practice Address - Country:US
Practice Address - Phone:208-425-9161
Practice Address - Fax:208-425-3809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X
ID251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID08051088Medicaid