Healthcare Provider Details

I. General information

NPI: 1376752675
Provider Name (Legal Business Name): LAGUNA EARLY CHILDHOOD PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40 WEST EXIT 114 BLDG 1125
LAGUNA NM
87026-0798
US

IV. Provider business mailing address

PO BOX 798
LAGUNA NM
87026-0798
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-6467
  • Fax: 505-552-0701
Mailing address:
  • Phone: 505-552-6467
  • Fax: 505-552-0701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number02204985001
License Number StateNM

VIII. Authorized Official

Name: MR. GILBERT SANCHEZ
Title or Position: SUPERINTENDENT
Credential: MASTERS EDUCATION
Phone: 505-552-6008