Provider Demographics
NPI:1427117761
Name:POLK SCHOOL DISTRICT
Entity type:Organization
Organization Name:POLK SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:VASSAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-884-9900
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:612 S. COLLEGE ST
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125
Mailing Address - Country:US
Mailing Address - Phone:770-748-3821
Mailing Address - Fax:770-748-5131
Practice Address - Street 1:612 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-3522
Practice Address - Country:US
Practice Address - Phone:770-684-8718
Practice Address - Fax:770-684-3221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2012-10-09
Deactivation Date:2008-06-03
Deactivation Code:
Reactivation Date:2008-09-16
Provider Licenses
StateLicense IDTaxonomies
GA235Z00000N235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
103071OtherWEB PORTAL SUBMISSION NUMBER
GA000795935AMedicaid