Healthcare Provider Details

I. General information

NPI: 1972620631
Provider Name (Legal Business Name): ESPANOLA VALLEY HIGH SCHOOL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

IV. Provider business mailing address

RR 4 BOX 200-4
HERNANDEZ NM
87537-9719
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-3420
  • Fax:
Mailing address:
  • Phone: 505-753-7844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberRN # R39189
License Number StateNM

VIII. Authorized Official

Name: DAVID COCKERHAM
Title or Position: SUPERINTENDENT
Credential:
Phone: 505-753-2254