Provider Demographics
NPI:1649311721
Name:CITIZENS FOR THE DEVELOPMENTALLY DISABLED, INC.
Entity type:Organization
Organization Name:CITIZENS FOR THE DEVELOPMENTALLY DISABLED, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEDOUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-445-5674
Mailing Address - Street 1:PO BOX 1589
Mailing Address - Street 2:230 4TH AVE.
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-1589
Mailing Address - Country:US
Mailing Address - Phone:505-445-5674
Mailing Address - Fax:505-445-8254
Practice Address - Street 1:230 4TH AVE
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-2643
Practice Address - Country:US
Practice Address - Phone:505-445-5674
Practice Address - Fax:505-445-8254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01135142000251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7272Medicaid
NMD0208Medicaid