=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154831451
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANANSI CHARTER SCHOOL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2017
-----------------------------------------------------
Last Update Date | 10/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 STATE HIGHWAY 230
-----------------------------------------------------
City | EL PRADO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-776-2256
-----------------------------------------------------
Fax | 575-776-5561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 STATE HIGHWAY 230
-----------------------------------------------------
City | EL PRADO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-776-2256
-----------------------------------------------------
Fax | 575-776-5561
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | RAYNE MEDINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 575-776-2256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251300000X
-----------------------------------------------------
Taxonomy Name | Local Education Agency (LEA)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------