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General NPI Number Information
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NPI Number | 1720331697
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Entity Type | Organization
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Legal Business Name | NORTHWEST REIONAL EDUCATION COOP #2
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Dates
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Enumeration Date | 10/17/2012
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Last Update Date | 02/08/2013
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Provider Practice Location Address
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Address Line | 91 HAWK DRIVE
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City | DULCE
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State | NM
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Zip | 87528
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Country | US
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Telephone | 575-759-2909
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Fax | 575-759-3533
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Provider Business Mailing Address
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Address Line | PO BOX 113
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City | CHAMA
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State | NM
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Zip | 87520-0113
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Country | US
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Telephone | 575-756-1274
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Fax | 575-756-1278
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Authorized Official
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Title or Position | DIRECTOR
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Name | KIMBERLY MIZELL
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Credential | PHDC.
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Telephone | 575-756-1274
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 02314459009
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 251300000X
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Taxonomy Name | Local Education Agency (LEA)
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License Number | 02314459009
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License Number State | NM
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