MEDICARE: SOUTH FORK UNION 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)

General Provider Information

NPI Number	:	1619153004
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH FORK UNION SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	5225 S KELSO VALLEY RD
Second Line	:
City	:	WELDON
State	:	CA
Zip	:	93283-9564
Country	:	US
Telephone Number	:	760-378-4000
Fax Number	:	760-378-3046

Provider Business Practice Location Address
First Line	:	5225 S KELSO VALLEY RD
Second Line	:
City	:	WELDON
State	:	CA
Zip	:	93283-9564
Country	:	US
Telephone Number	:	760-378-4000
Fax Number	:	760-378-3046

Authorized Official
Title or Position	:	SUPERINTENDENT/PRINCIPAL
Name	:	SHERRY NICHOLS
Credential	:
Telephone Number	:	760-378-4000

Provider Enumeration Date	:	01/15/2008
Last Update Date	:	11/01/2011

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