Healthcare Provider Details

I. General information

NPI: 1720331697
Provider Name (Legal Business Name): NORTHWEST REIONAL EDUCATION COOP #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 02/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 HAWK DRIVE
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 113
CHAMA NM
87520-0113
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-2909
  • Fax: 575-759-3533
Mailing address:
  • Phone: 575-756-1274
  • Fax: 575-756-1278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number02314459009
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number02314459009
License Number StateNM

VIII. Authorized Official

Name: KIMBERLY MIZELL
Title or Position: DIRECTOR
Credential: PHDC.
Phone: 575-756-1274