Provider Demographics
NPI:1295232734
Name:LAS CUMBRES COMMUNITY SERVICES
Entity Type:Organization
Organization Name:LAS CUMBRES COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BISSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:857-523-0654
Mailing Address - Street 1:102 N CORONADO AVE
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2700
Mailing Address - Country:US
Mailing Address - Phone:505-629-1813
Mailing Address - Fax:505-747-0421
Practice Address - Street 1:404 HUNTER ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2655
Practice Address - Country:US
Practice Address - Phone:505-753-4123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NME7436252Y00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7436Medicaid