Provider Demographics
NPI:1487798567
Name:CENTRAL CONSOLIDATED SCHOOL DISTRICT #22
Entity type:Organization
Organization Name:CENTRAL CONSOLIDATED SCHOOL DISTRICT #22
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAID SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-368-5163
Mailing Address - Street 1:PO BOX 1319
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1319
Mailing Address - Country:US
Mailing Address - Phone:505-368-5163
Mailing Address - Fax:505-368-5502
Practice Address - Street 1:US HWY 64 OLD HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-5163
Practice Address - Fax:505-368-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
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
NMJ7695Medicaid