Basic Information
| Provider Information | |||||||||
| NPI: | 1851301857 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAS CRUCES SCHOOL DISTRICT NO. 2 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055275884 | ||||||||
| FaxNumber: | 5055275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST STE 249 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275823 | ||||||||
| FaxNumber: | 5055275886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | TINGUELY | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAID SCHOOL BASED SERVICES COOR | ||||||||
| AuthorizedOfficialTelephone: | 5755275823 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | NM | N | 193200000X MULTI-SPECIALTY GROUP | Student, Health Care | Student in an Organized Health Care Education/Training Program | 251300000X | Y | Agencies | Local Education Agency (LEA) |
ID Information
| ID | Type | State | Issuer | Description | E7687 | 05 | NM | MEDICAID |