1720331697 NPI number — NORTHWEST REIONAL EDUCATION COOP #2

Table of content: (NPI 1720331697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720331697 NPI number — NORTHWEST REIONAL EDUCATION COOP #2

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST REIONAL EDUCATION COOP #2
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:
DULCE SCHOOL BASED HEALTH CENTER
Provider Other Organization Name Type Code:
3
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:
1720331697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 113
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHAMA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87520-0113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-756-1274
Provider Business Mailing Address Fax Number:
575-756-1278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
91 HAWK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULCE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-759-2909
Provider Business Practice Location Address Fax Number:
575-759-3533
Provider Enumeration Date:
10/17/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MIZELL
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
575-756-1274

Provider Taxonomy Codes

  • Taxonomy code: 251300000X , with the licence number:  02314459009 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: 02314459009 , 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)





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