MEDICARE: DEMOCRACY PREP AGASSI CAMPUS

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)

General Provider Information

NPI Number	:	1649830944
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEMOCRACY PREP AGASSI CAMPUS

Provider Business Mailing Address
First Line	:	1201 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2411
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-2411
Country	:	US
Telephone Number	:	702-316-2410
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF SPECIAL EDUCATION
Name	:	ELLIE M GROSE
Credential	:
Telephone Number	:	347-501-0187

Provider Enumeration Date	:	06/18/2019
Last Update Date	:	06/18/2019

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