Healthcare Provider Details

I. General information

NPI: 1265362735
Provider Name (Legal Business Name): NORTHEAST REGIONAL EDUCATION COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 11TH ST.
LAS VEGAS NM
87701
US

IV. Provider business mailing address

1031 11TH ST.
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 505-459-8118
  • Fax:
Mailing address:
  • Phone: 505-555-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN PORTLEY
Title or Position: EXEC. DIRECTOR
Credential: PH.D
Phone: 505-459-8118