Healthcare Provider Details

I. General information

NPI: 1114678182
Provider Name (Legal Business Name): BROKEN BOW PUBLIC SCHOOLS COUNTY OF CUSTER SCHOOL DISTRICT 25
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/12/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N 7TH AVE
BROKEN BOW NE
68822-1718
US

IV. Provider business mailing address

323 N 7TH AVE
BROKEN BOW NE
68822-1718
US

V. Phone/Fax

Practice location:
  • Phone: 308-872-6821
  • Fax: 308-872-2751
Mailing address:
  • Phone: 308-872-6821
  • Fax: 308-872-2751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA E MAYOR-GASTON
Title or Position: SPED ADMINISTRATIVE ASSISTANT
Credential:
Phone: 308-872-6821