MEDICARE: PAINTED DESERT DEMONSTRATION PROJECT

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)		AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	908600	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1922208099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAINTED DESERT DEMONSTRATION PROJECT

Provider Business Mailing Address
First Line	:	145 LEUPP RD
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-8501
Country	:	US
Telephone Number	:	602-412-3533
Fax Number	:	928-225-2179

Provider Business Practice Location Address
First Line	:	145 LEUPP RD
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86004-8501
Country	:	US
Telephone Number	:	602-412-3533
Fax Number	:	928-225-2179

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. MARK SORENSEN
Credential	:	ED.D
Telephone Number	:	602-412-3533

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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