Provider Demographics
NPI:1003284654
Name:COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE
Entity Type:Organization
Organization Name:COMPOSTELA COMMUNITY AND FAMILY CULTURAL INSTITUTE
Other - Org Name:CC&FCI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TRINIDAD
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:ARGUELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,LISW, PMHBC-RN
Authorized Official - Phone:575-776-2752
Mailing Address - Street 1:PO BOX 2173
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-2173
Mailing Address - Country:US
Mailing Address - Phone:575-776-2752
Mailing Address - Fax:
Practice Address - Street 1:1021 SALAZAR RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-8233
Practice Address - Country:US
Practice Address - Phone:575-613-2008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-11
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR12314251B00000X, 251X00000X
NM12732251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH6196Medicaid
NM163W00000XOtherREGISTERED NURSE R12314
NM1841242336OtherNPI
NMMHC51409Medicaid
NM343511902OtherMEDICARE