MEDICARE: FORT SUMNER SCHOOLS

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	251J00000X	Nursing Care Agency	R28287	NM

General Provider Information

NPI Number	:	1891209235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT SUMNER SCHOOLS

Provider Business Mailing Address
First Line	:	765 EAST SUMNER AVENUE
Second Line	:
City	:	FORT SUMNER
State	:	NM
Zip	:	88119
Country	:	US
Telephone Number	:	575-355-7766
Fax Number	:	575-355-6002

Provider Business Practice Location Address
First Line	:	262 SOUTH 9TH STREET
Second Line	:	ELEMENTARY SCHOOL BUILDING
City	:	FORT SUMNER
State	:	NM
Zip	:	88119-9316
Country	:	US
Telephone Number	:	575-355-7716
Fax Number	:	575-355-6002

Authorized Official
Title or Position	:	SCHOOL NURSE
Name	:	MARIE ALICE DICKERMAN
Credential	:	REGISTERED NURSE
Telephone Number	:	575-355-7766

Provider Enumeration Date	:	11/21/2017
Last Update Date	:	11/21/2017

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