1609318112 NPI number — ROOTS & WINGS COMMUNITY CHARTER SCHOOL

Table of content: (NPI 1609318112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609318112 NPI number — ROOTS & WINGS COMMUNITY CHARTER SCHOOL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROOTS & WINGS COMMUNITY CHARTER SCHOOL
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:
1609318112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 81, P.O. BOX 22
Provider Second Line Business Mailing Address:
35 LA LAMA ROAD
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87556
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-585-2076
Provider Business Mailing Address Fax Number:
575-586-2087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 LA LAMA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-585-2076
Provider Business Practice Location Address Fax Number:
575-586-2087
Provider Enumeration Date:
11/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ARCHULETA
Authorized Official First Name:
CHARLOTTE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BUSINESS MANAGER/CPO
Authorized Official Telephone Number:
505-450-1415

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  000T6366 , 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: 1376509448 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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