Provider Demographics
NPI:1144575044
Name:REGIONAL EDUCATIONAL CENTER #6
Entity Type:Organization
Organization Name:REGIONAL EDUCATIONAL CENTER #6
Other - Org Name:SAN JON SCHOOL BASED CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-562-4455
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0847
Mailing Address - Country:US
Mailing Address - Phone:575-562-4455
Mailing Address - Fax:575-562-4460
Practice Address - Street 1:7TH & ELM STREET
Practice Address - Street 2:
Practice Address - City:SAN JON
Practice Address - State:NM
Practice Address - Zip Code:88434
Practice Address - Country:US
Practice Address - Phone:575-576-2273
Practice Address - Fax:575-576-2273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM101YM0800X, 390200000X
251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29371571Medicaid