MEDICARE: PACIFIC ELEMENTARY SCHOOL DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1134945991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC ELEMENTARY SCHOOL DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX H
Second Line	:
City	:	DAVENPORT
State	:	CA
Zip	:	95017-1007
Country	:	US
Telephone Number	:	831-425-7002
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 OCEAN ST.
Second Line	:
City	:	DAVENPORT
State	:	CA
Zip	:	95017-1107
Country	:	US
Telephone Number	:	831-425-7002
Fax Number	:

Authorized Official
Title or Position	:	SUPERINTENDENT/PRINCIPAL
Name	:	MR. JAMES ERIC GROSS
Credential	:
Telephone Number	:	831-425-7002

Provider Enumeration Date	:	11/26/2024
Last Update Date	:	11/26/2024

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