1003284654 NPI number — COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE

Table of content: (NPI 1003284654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003284654 NPI number — COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE
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:
Provider Other Organization Name Type Code:
6
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:
1003284654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2173
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PRADO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87529-2173
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-776-2752
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 SALAZAR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87571-8233
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-613-2008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ARGUELLO
Authorized Official First Name:
TRINIDAD
Authorized Official Middle Name:
DE JESUS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
575-776-2752

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  R12314 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251X00000X , with the licence number: R12314 , 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: 12732 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: H6196 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 163W00000X . This is a "REGISTERED NURSE R12314" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 1841242336 . This is a "NPI" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: MHC51409 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 343511902 . This is a "MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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