Provider Demographics
NPI:1013190610
Name:ROBERT F. KENNEDY CHARTER HIGH SCHOOL
Entity Type:Organization
Organization Name:ROBERT F. KENNEDY CHARTER HIGH SCHOOL
Other - Org Name:ROBERT F. KENNEDY SCHOOL BASED HEATH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ROBERT. F. KENNEDY SBHC COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:KAUEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-239-7589
Mailing Address - Street 1:4300 BLAKE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121
Mailing Address - Country:US
Mailing Address - Phone:505-243-1118
Mailing Address - Fax:505-242-7444
Practice Address - Street 1:4300 BLAKE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121
Practice Address - Country:US
Practice Address - Phone:505-243-1118
Practice Address - Fax:505-242-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251S00000X, 261Q00000X
NM3201078041291U00000X
NMCL00D1106443336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251S00000XAgenciesCommunity/Behavioral Health
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1C01Medicaid