Healthcare Provider Details

I. General information

NPI: 1154726776
Provider Name (Legal Business Name): NEW MEXICO AFTER SCHOOL ENRICHMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3777 CORRALES RD
CORRALES NM
87048-9140
US

IV. Provider business mailing address

3777 CORRALES RD
CORRALES NM
87048-9140
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-1793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1147
License Number StateNM

VIII. Authorized Official

Name: ROBERT HOBBS
Title or Position: CEO
Credential: MPH, OTR/L
Phone: 505-379-1793