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General NPI Number Information
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NPI Number | 1699245050
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Entity Type | Organization
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Legal Business Name | CHARLIE MIKE BASE CAMP
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Dates
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Enumeration Date | 11/28/2018
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Last Update Date | 11/28/2018
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Provider Practice Location Address
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Address Line | 225 E IDAHO AVE STE 27
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City | LAS CRUCES
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State | NM
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Zip | 88005-3242
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Country | US
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Telephone | 575-571-1016
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1676
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City | FAIRACRES
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State | NM
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Zip | 88033-1676
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Country | US
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Telephone | 575-571-1016
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | CHARLES GATES
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Credential |
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Telephone | 575-571-1016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174200000X
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Taxonomy Name | Meals Provider
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332U00000X
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Taxonomy Name | Home Delivered Meals
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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