Healthcare Provider Details

I. General information

NPI: 1215374855
Provider Name (Legal Business Name): PEANUT BUTTER AND JELLY FAMILY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 SAN PABLO ST SE
ALBUQUERQUE NM
87108-3103
US

IV. Provider business mailing address

209 SAN PABLO ST SE
ALBUQUERQUE NM
87108-3103
US

V. Phone/Fax

Practice location:
  • Phone: 505-944-7224
  • Fax: 505-944-7229
Mailing address:
  • Phone: 505-944-7224
  • Fax: 505-944-7229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number154065
License Number StateNM

VIII. Authorized Official

Name: MRS. ANGELA LOVATO
Title or Position: TEACHER
Credential: BSW
Phone: 505-944-7224