Provider Demographics
NPI:1720331697
Name:NORTHWEST REIONAL EDUCATION COOP #2
Entity Type:Organization
Organization Name:NORTHWEST REIONAL EDUCATION COOP #2
Other - Org Name:DULCE SCHOOL BASED HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHDC
Authorized Official - Phone:575-756-1274
Mailing Address - Street 1:PO BOX 113
Mailing Address - Street 2:
Mailing Address - City:CHAMA
Mailing Address - State:NM
Mailing Address - Zip Code:87520-0113
Mailing Address - Country:US
Mailing Address - Phone:575-756-1274
Mailing Address - Fax:575-756-1278
Practice Address - Street 1:91 HAWK DRIVE
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-2909
Practice Address - Fax:575-759-3533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02314459009251300000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)Group - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty