MEDICARE: TAYLOR'S CROSSING PUBLIC CHARTER SCHOOL

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)		ID

General Provider Information

NPI Number	:	1790937159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAYLOR'S CROSSING PUBLIC CHARTER SCHOOL

Provider Business Mailing Address
First Line	:	1445 N WOOD RIVER DRIVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401
Country	:	US
Telephone Number	:	208-522-0397
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 N WOOD RIVER DRIVE
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401
Country	:	US
Telephone Number	:	208-522-0397
Fax Number	:	208-529-2755

Authorized Official
Title or Position	:	SYSTEMS MANAGER
Name	:	TODD LEVESQUE
Credential	:
Telephone Number	:	208-922-9300

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	10/16/2008

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Directions to “TAYLOR'S CROSSING PUBLIC CHARTER SCHOOL ” Practice Location

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