Provider Demographics
NPI:1841493491
Name:COACHES KORNER & THE EMPOWERMENT CENTER OF NEW MEXICO LLC
Entity type:Organization
Organization Name:COACHES KORNER & THE EMPOWERMENT CENTER OF NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:AYDREN
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:505-203-6164
Mailing Address - Street 1:5555 ZUNI RD SE STE 20-277
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2942
Mailing Address - Country:US
Mailing Address - Phone:505-203-6164
Mailing Address - Fax:
Practice Address - Street 1:901 INDIANA ST SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4903
Practice Address - Country:US
Practice Address - Phone:505-203-6164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0103731251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health