Healthcare Provider Details

I. General information

NPI: 1295232734
Provider Name (Legal Business Name): LAS CUMBRES COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HUNTER ST
ESPANOLA NM
87532-2655
US

IV. Provider business mailing address

102 N CORONADO AVE
ESPANOLA NM
87532-2700
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-4123
  • Fax:
Mailing address:
  • Phone: 505-629-1813
  • Fax: 505-747-0421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberE7436
License Number StateNM

VIII. Authorized Official

Name: AMANDA J BISSELL
Title or Position: COO
Credential: MPH
Phone: 857-523-0654