Provider Demographics
NPI:1740784198
Name:FNCH SBHC NACA HIGH SCHOOL
Entity Type:Organization
Organization Name:FNCH SBHC NACA HIGH SCHOOL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WIDENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-262-6588
Mailing Address - Street 1:5608 ZUNI RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2926
Mailing Address - Country:US
Mailing Address - Phone:505-262-6588
Mailing Address - Fax:505-262-7045
Practice Address - Street 1:1711 STANFORD DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2535
Practice Address - Country:US
Practice Address - Phone:505-262-2481
Practice Address - Fax:505-265-7045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST NATIONS COMMUNITY HEALTH SOURCE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00046912Medicaid