1649311721 NPI number — CITIZENS FOR THE DEVELOPMENTALLY DISABLED, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649311721 NPI number — CITIZENS FOR THE DEVELOPMENTALLY DISABLED, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITIZENS FOR THE DEVELOPMENTALLY DISABLED, INC.
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:
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:
1649311721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1589
Provider Second Line Business Mailing Address:
230 4TH AVE.
Provider Business Mailing Address City Name:
RATON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87740-1589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-445-5674
Provider Business Mailing Address Fax Number:
505-445-8254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740-2643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-445-5674
Provider Business Practice Location Address Fax Number:
505-445-8254
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEDOUX
Authorized Official First Name:
BOBBY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
505-445-5674

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  01135142000 , 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: E7272 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: D0208 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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