MEDICARE: EAGLE MOUNTAIN SAGINAW ISD

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	251K00000X	Public Health or Welfare Agency	AT6567	TX

General Provider Information

NPI Number	:	1851848402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE MOUNTAIN SAGINAW ISD

Provider Business Mailing Address
First Line	:	800 N BLUE MOUND RD
Second Line	:
City	:	SAGINAW
State	:	TX
Zip	:	76131
Country	:	US
Telephone Number	:	505-977-0419
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 N BLUE MOUND RD
Second Line	:
City	:	SAGINAW
State	:	TX
Zip	:	76131-1052
Country	:	US
Telephone Number	:	505-977-0419
Fax Number	:

Authorized Official
Title or Position	:	SCHOOL DISTRICT ATHLETIC DIRECTOR
Name	:	BRENT BARKER
Credential	:
Telephone Number	:	817-232-0880

Provider Enumeration Date	:	09/01/2016
Last Update Date	:	09/01/2016

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