Provider Demographics
NPI:1497000954
Name:RAVENSNOW L.L.C.
Entity Type:Organization
Organization Name:RAVENSNOW L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CORKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ST. JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:LLC
Authorized Official - Phone:505-830-6030
Mailing Address - Street 1:3150 CARLISLE BLVD NE
Mailing Address - Street 2:STE 22
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-1679
Mailing Address - Country:US
Mailing Address - Phone:505-830-6030
Mailing Address - Fax:505-830-6031
Practice Address - Street 1:3150 CARLISLE BLVD NE
Practice Address - Street 2:STE 22
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1679
Practice Address - Country:US
Practice Address - Phone:505-830-6030
Practice Address - Fax:505-830-6031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3888251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health