Provider Demographics
NPI:1790828341
Name:PENASCO INDEPENDENT SCHOOLS
Entity Type:Organization
Organization Name:PENASCO INDEPENDENT SCHOOLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-587-2395
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:PENASCO
Mailing Address - State:NM
Mailing Address - Zip Code:87553-0520
Mailing Address - Country:US
Mailing Address - Phone:505-587-2395
Mailing Address - Fax:505-587-2513
Practice Address - Street 1:13 SCHOOL ROAD HWY 75
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553-0520
Practice Address - Country:US
Practice Address - Phone:505-587-2395
Practice Address - Fax:505-587-2513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP6722Medicaid