MEDICARE: CANON ELEMENTARY 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	251300000X	Local Education Agency (LEA)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	55820825	OTHER	AZ	USER ID

General Provider Information

NPI Number	:	1508079518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANON ELEMENTARY SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 89
Second Line	:	34630 S SCHOOL LOOP RD
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-0089
Country	:	US
Telephone Number	:	623-374-5588
Fax Number	:

Provider Business Practice Location Address
First Line	:	34630 S SCHOOL LOOP RD.
Second Line	:
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-0089
Country	:	US
Telephone Number	:	623-374-5588
Fax Number	:	623-374-5046

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MRS. VICKI ELKINS
Credential	:
Telephone Number	:	623-374-5588

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	08/22/2020

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Directions to “CANON ELEMENTARY SCHOOL DISTRICT ” Practice Location

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