Provider Demographics
NPI:1609318112
Name:ROOTS & WINGS COMMUNITY CHARTER SCHOOL
Entity Type:Organization
Organization Name:ROOTS & WINGS COMMUNITY CHARTER SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER/CPO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLOTTE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARCHULETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-450-1415
Mailing Address - Street 1:HC 81, P.O. BOX 22
Mailing Address - Street 2:35 LA LAMA ROAD
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87556
Mailing Address - Country:US
Mailing Address - Phone:575-585-2076
Mailing Address - Fax:575-586-2087
Practice Address - Street 1:35 LA LAMA ROAD
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87556
Practice Address - Country:US
Practice Address - Phone:575-585-2076
Practice Address - Fax:575-586-2087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM000T6366302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1376509448Medicaid