Basic Information
| Provider Information | |||||||||
| NPI: | 1295232734 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAS CUMBRES COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N CORONADO AVE | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056291813 | ||||||||
| FaxNumber: | 5057470421 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 HUNTER ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057534123 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | BISSELL | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 8575230654 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 252Y00000X | E7436 | NM | Y | Agencies | Early Intervention Provider Agency |
ID Information
| ID | Type | State | Issuer | Description | E7436 | 05 | NM | MEDICAID |