Healthcare Provider Details

I. General information

NPI: 1508079518
Provider Name (Legal Business Name): CANON ELEMENTARY SCHOOL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34630 S SCHOOL LOOP RD.
BLACK CANYON CITY AZ
85324-0089
US

IV. Provider business mailing address

PO BOX 89 34630 S SCHOOL LOOP RD
BLACK CANYON CITY AZ
85324-0089
US

V. Phone/Fax

Practice location:
  • Phone: 623-374-5588
  • Fax: 623-374-5046
Mailing address:
  • Phone: 623-374-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MRS. VICKI ELKINS
Title or Position: SUPERINTENDENT
Credential:
Phone: 623-374-5588