MEDICARE: BLACK OAK MINE UNIFIED SCHOOL DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1043181563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK OAK MINE UNIFIED SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	9080 COUNTRY RD
Second Line	:
City	:	GEORGETOWN
State	:	CA
Zip	:	95634-9732
Country	:	US
Telephone Number	:	530-903-9188
Fax Number	:

Provider Business Practice Location Address
First Line	:	6530 WENTWORTH SPRINGS RD
Second Line	:
City	:	GEORGETOWN
State	:	CA
Zip	:	95634-9701
Country	:	US
Telephone Number	:	530-333-8320
Fax Number	:

Authorized Official
Title or Position	:	WELLNESS COACH
Name	:	CLORISA LYNN BLISH
Credential	:	CWCII WELLNESS COACH
Telephone Number	:	530-903-9188

Provider Enumeration Date	:	09/16/2025
Last Update Date	:	09/16/2025

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