Basic Information
| Provider Information | |||||||||
| NPI: | 1740378397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNNYSIDE UNIFIED SCHOOL DISTRICT NO. 12 | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUNNYSIDE SCHOOL DISTRICT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2238 E GINTER RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857065806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205452137 | ||||||||
| FaxNumber: | 5205452120 | ||||||||
| Practice Location | |||||||||
| Address1: | 2238 E GINTER RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857065806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205452137 | ||||||||
| FaxNumber: | 5205452120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STORM | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SUPERINTENDENT OF STUDENT | ||||||||
| AuthorizedOfficialTelephone: | 5205452065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| 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 | 546541 | 05 | AZ | MEDICAID |