1053460287 NPI number — LAS CUMBRES COMMUNITY SERVICES

Table of content: (NPI 1053460287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053460287 NPI number — LAS CUMBRES COMMUNITY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAS CUMBRES COMMUNITY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAS CUMBRES LEARNING SERVICES
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053460287
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 N CORONADO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESPANOLA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87532-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
857-523-0654
Provider Business Mailing Address Fax Number:
505-753-6947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 HUNTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESPANOLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87532-2655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-753-4123
Provider Business Practice Location Address Fax Number:
505-753-6947
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BISSELL
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
857-523-0654

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  6652 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 6652 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385HR2055X , with the licence number: 6653 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1053460287 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: E7436 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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