Healthcare Provider Details

I. General information

NPI: 1790828341
Provider Name (Legal Business Name): PENASCO INDEPENDENT SCHOOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 SCHOOL ROAD HWY 75
PENASCO NM
87553-0520
US

IV. Provider business mailing address

PO BOX 520
PENASCO NM
87553-0520
US

V. Phone/Fax

Practice location:
  • Phone: 505-587-2395
  • Fax: 505-587-2513
Mailing address:
  • Phone: 505-587-2395
  • Fax: 505-587-2513

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. RUDY J MONTOYA
Title or Position: ASSISTANT SUPERINTENDENT
Credential:
Phone: 505-587-2395