Healthcare Provider Details

I. General information

NPI: 1568801017
Provider Name (Legal Business Name): COLLINS LAKE AUTISM CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 ENCINAL ROAD
CLEVELAND NM
87715
US

IV. Provider business mailing address

710 GILDERSLEEVE ST
SANTA FE NM
87505-2636
US

V. Phone/Fax

Practice location:
  • Phone: 281-630-0827
  • Fax:
Mailing address:
  • Phone: 281-630-0827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN ANDREW SMABY
Title or Position: FOUNDER
Credential:
Phone: 281-630-0827