MEDICARE: COACHES KORNER & THE EMPOWERMENT CENTER OF NEW MEXICO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	0103731	NM
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1841493491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COACHES KORNER & THE EMPOWERMENT CENTER OF NEW MEXICO LLC

Provider Business Mailing Address
First Line	:	5555 ZUNI RD SE STE 20-277
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87108-2942
Country	:	US
Telephone Number	:	505-203-6164
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 MOON ST NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-2709
Country	:	US
Telephone Number	:	505-203-6164
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY AYDREN MCNEIL
Credential	:
Telephone Number	:	505-203-6164

Provider Enumeration Date	:	06/08/2007
Last Update Date	:	05/11/2026

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