Healthcare Provider Details

I. General information

NPI: 1982911079
Provider Name (Legal Business Name): EDUCATIONAL SERVICE DISTRICT 112
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE 65TH AVE
VANCOUVER WA
98661-6812
US

IV. Provider business mailing address

2500 NE 65 AVE
VANCOUVER WA
98661-6812
US

V. Phone/Fax

Practice location:
  • Phone: 360-750-7500
  • Fax: 360-906-1010
Mailing address:
  • Phone: 360-750-7500
  • Fax: 360-906-1010

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: TIM MERLINO
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 360-750-7500