=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588092548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPISTRANO CONNECTION ACADEMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2013
-----------------------------------------------------
Last Update Date | 01/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33272 VALLE RD
-----------------------------------------------------
City | SAN JUAN CAPISTRANO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92675-4842
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-461-1667
-----------------------------------------------------
Fax | 949-425-8791
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 SW COLUMBIA ST SUITE 1750
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97201-6600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-461-1667
-----------------------------------------------------
Fax | 949-425-8791
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPAL
-----------------------------------------------------
Name | RICHARD SAVAGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-461-1667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------