Healthcare Provider Details

I. General information

NPI: 1134945991
Provider Name (Legal Business Name): PACIFIC ELEMENTARY SCHOOL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 OCEAN ST.
DAVENPORT CA
95017-1107
US

IV. Provider business mailing address

PO BOX H
DAVENPORT CA
95017-1007
US

V. Phone/Fax

Practice location:
  • Phone: 831-425-7002
  • Fax:
Mailing address:
  • Phone: 831-425-7002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES ERIC GROSS
Title or Position: SUPERINTENDENT/PRINCIPAL
Credential:
Phone: 831-425-7002