Provider Demographics
NPI:1861630410
Name:LA CLINICA DEL PUEBLO DE RIO ARRIAB
Entity Type:Organization
Organization Name:LA CLINICA DEL PUEBLO DE RIO ARRIAB
Other - Org Name:ESCALANTE SCHOOL BASE HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DE YAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-588-7252
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:US HWY 84, COUNTY RD. 0324, #14
Mailing Address - City:TIERRA AMARILLA
Mailing Address - State:NM
Mailing Address - Zip Code:87575-0250
Mailing Address - Country:US
Mailing Address - Phone:575-588-7252
Mailing Address - Fax:575-588-9132
Practice Address - Street 1:U S HWY 84, COUNTY ROAD 0324, #14
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575-0250
Practice Address - Country:US
Practice Address - Phone:575-588-7252
Practice Address - Fax:575-588-9132
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DEL PUEBLO DE RIO ARRIBA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-04
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6253261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1336177575OtherSANCHEZ, JOYCE M., LISW, LADAC
NM1114908761OtherKNACKSTEDT, SHIRLEY, CFNP
NM1114908761OtherKNACKSTEDT, SHIRLEY, CFNP
NM172396229OtherFUTRELL, ANNA R. LMFT