Healthcare Provider Details

I. General information

NPI: 1013190610
Provider Name (Legal Business Name): ROBERT F. KENNEDY CHARTER HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 BLAKE SW
ALBUQUERQUE NM
87121
US

IV. Provider business mailing address

4300 BLAKE SW
ALBUQUERQUE NM
87121
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-1118
  • Fax: 505-242-7444
Mailing address:
  • Phone: 505-243-1118
  • Fax: 505-242-7444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number3201078041
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberCL00D110644
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNM

VIII. Authorized Official

Name: MS. BONNIE K. KAUEMAN
Title or Position: ROBERT. F. KENNEDY SBHC COORDINATOR
Credential: RN
Phone: 505-239-7589