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General NPI Number Information
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NPI Number | 1841493491
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Entity Type | Organization
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Legal Business Name | COACHES KORNER & THE EMPOWERMENT CENTER OF NEW MEXICO LLC
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Dates
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Enumeration Date | 06/08/2007
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 901 INDIANA ST SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87108-4903
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Country | US
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Telephone | 505-203-6164
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Fax |
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Provider Business Mailing Address
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Address Line | 5555 ZUNI RD SE STE 20-277
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City | ALBUQUERQUE
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State | NM
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Zip | 87108-2942
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Country | US
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Telephone | 505-203-6164
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. GREGORY AYDREN MCNEIL
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Credential | LPCC
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Telephone | 505-203-6164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0103731
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License Number State | NM
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