Healthcare Provider Details

I. General information

NPI: 1245312719
Provider Name (Legal Business Name): REGION IX EDUCATION COOPERATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 SUDDERTH DR
RUIDOSO NM
88345-6103
US

IV. Provider business mailing address

1400 SUDDERTH DR
RUIDOSO NM
88345-6103
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-2368
  • Fax: 505-257-2141
Mailing address:
  • Phone: 505-257-2368
  • Fax: 505-257-2141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number257884
License Number StateNM

VIII. Authorized Official

Name: EVELYN SANCHEZ
Title or Position: MEDICAID SERVICES TECHNICIAN
Credential:
Phone: 505-257-2368